Medicaid Benefit Information


Benefit: Ambulance

 

Definition: Florida covers transportation by ambulance to the nearest hospital for emergency treatment. Transportation is also generally available by helicopter when medically necessary. Ambulance transportation is also available for non-emergency trips for health care when other modes of travel are not medically appropriate.

Limits:  All ambulance transportation must be the most cost-effective and most appropriate method of transportation available. A physician’s order (non-emergency transportation ) and documentation of medical necessity (emergency transportation), and in some cases prior approval, is typically required.

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Ambulatory Surgery

 

Definition: Ambulatory Surgery is a procedure that is more intensive than one done in the average doctor's office but not so intensive as to require a hospital stay. It covers surgical procedures that have been approved by the federal Centers for Medicare and Medicaid Services (CMS), that are provided in a licensed, Medicare-approved, Medicaid-participating facility that is not part of a hospital.

Limits: Surgical procedures are limited to services that:

  • Are normally not emergency or life threatening in nature;
  • Do not exceed a total of 90 minutes operating time;
  • Do not exceed a total of four hours recovery or convalescent time;
  • Do not require major invasion of body cavities or directly involve major blood vessels;
  • Do not usually result in heavy loss of blood; and
  • Require a dedicated operating room.
Anesthesia is limited to local, regional or general anesthesia that lasts 90 minutes or less.

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Chemotherapy Services

 

Definition: The term chemotherapy, which is sometimes shortened to chemo, refers to the use of medications to treat cancer. Chemo is given by an oncologist, a doctor who treats cancer, who works with other health care professionals to decide on the type of chemotherapy treatment that will work best for each individual cancer patient. Chemo can be given in many different ways, including:

  • Intravenously (IV). A needle is inserted into a vein and the medicine flows from an IV bag or bottle into the bloodstream.
  • Orally. The person getting treatment swallows a pill, capsule, or liquid form of chemo medication.
  • By injection. Using a needle or syringe, the drugs are injected into a muscle or under the skin.

The kind of therapy a person receives is based on the type of cancer that person has and whether it has spread to areas outside where it started. Most cancers are treated with more than one chemotherapy drug; doctors refer to this as combination chemotherapy. A person can receive chemotherapy treatments at a hospital, cancer treatment center, doctor's office, or at home. Some people receive chemotherapy every day; others receive it every week or every month.

Limits:  None

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Chiropractor

Definition:  A chiropractor is a complementary and alternative medicine health care professional who diagnoses and treats mechanical disorders of the spine and muscle system with the intention of improving health. Chiropractic services use manual treatments including spinal adjustment and other joint and soft-tissue manipulation. Chiropractic services include a new patient visit, follow-up manipulations of the spine, and spinal x-rays by a licensed, Medicaid participating chiropractor. The new patient visit consists of a screening and any required manipulation of the spine.

Limits: Medicaid reimbursement for chiropractic services is limited to one visit to a Medicaid authorized chiropractor, per recipient, per day.

A new patient visit is limited to one per provider, per recipient. A new patient is one who has not received any professional services from the provider or provider group within the past three years.

Visits are limited to a total of 24 medically necessary and appropriate visits during a calendar year.

Medicaid does not reimburse massage or heat treatments.

Exceptions:  The provider may request authorization to provide more than the 24 medically necessary visits for recipients 20 years of age or younger.

Co-pays: $1 copay for chiropractic services, per provider, per day, unless the beneficiary is exempt.

Reform items that can vary: # of visits can be limited; total annual amount can be limited; and co-pays can vary

 

Benefit: Clinic (FQHC and RHC)

 

Definition: A Federally Qualified Health Center (FQHC) is a clinic that provides primary and preventive outpatient health care.
 
A Rural Health Clinic (RHC) is a clinic that is located in a rural area that has a health care provider shortage. RHCs provide primary and preventive health care and related diagnostic services. In addition, RHCs may provide adult health screening services, Child Health Check-Ups, family planning services, optometric, podiatry, chiropractic and mental health services and the Vaccines for Children program.

FQHC and RHC services are performed by advanced registered nurse practitioners, chiropractors, psychologists, social workers, dentists, optometrists, physicians, physician assistants, and podiatrists.

Limits:  Services are limited to one visit, per day, per recipient. Any service that applies to another benefit, such as dental, must apply that specific limit also. For example, mental health services are limited to 26 visits per calendar year.

Exceptions: None

Co-pays: $3 copay for FQHC/RHC services, per clinic, per day, unless exempt.

Reform items that can vary: Copays may vary

 

Benefit: Dental Services – Adults 21 years old and older

 

Definition: Emergency dental procedures to alleviate pain or infection, dentures and denture-related procedures.

Adult dental services include:

  • Complete removable partial dentures;
  • Comprehensive oral evaluation;
  • Denture-related procedures;
  • Full dentures;
  • Incision and drainage of an abscess;
  • Necessary extractions and surgical procedures to fit the mouth for dentures;
  • Necessary x-rays/radiographs to make a diagnosis;
  • Problem-focused oral evaluation; and
  • Removable partial dentures.

Medicaid covers medically necessary emergency services.

Limits:  Evaluations for adults are limited to determining the need for dentures or for acute emergency services. Emergency services are limited to an emergency problem-focused evaluation, necessary x-rays to make a diagnosis, extraction, incision and drainage of an abscess.

Exceptions: None

Co-pays: Adult Medicaid beneficiaries are responsible for paying a 5 percent coinsurance charge for all procedures related to denture services, unless exempt.

Reform items that can vary: total annual amount can be limited; and co-pays can vary

 

Benefit: Dental Services – Children 20 and Under

 

Definition: Dental procedures performed by a licensed, Medicaid participating dentist. Services include:

  • Dentures, complete and partial;
  • Diagnostic examinations;
  • Endodontic (deals with the tooth insides and the tissues surrounding the root of a tooth)/ Periodontal (deals with diseases and conditions that affect the tooth’s supporting structure such as gums and jawbone) treatment;
  • Oral surgery;
  • Orthodontic (deals with tooth alignment from an improper bite) treatment;
  • Periodontal (deals with diseases and conditions that affect the tooth’s supporting structure such as gums and jawbone) services;
  • Preventive services;
  • Restorations; and
  • X-rays/radiographs necessary to make a diagnosis.

Limits:  Medicaid does not reimburse for the following services:

  • Fixed bridge work or sealants applied to deciduous (baby) teeth. Medicaid reimburses for the application of sealants on permanent first and second molars once per three years, per tooth.
  • For orthodontics, Medicaid services are limited to treatment of severe malocclusions or correction of a dental condition deterring physical development.

Prior authorization is required for partial dentures and all orthodontic services except the initial evaluation.

Exceptions: None

Co-pays: None

Reform items that can vary: total annual amount can be limited.

 

Benefit: Dialysis Services

 

Definition: Dialysis is a process that 1) uses a machine to purify the blood of waste and excess fluids or 2) injects a fluid into the abdominal cavity that causes excess fluids to drain out the body because the kidneys don’t work (renal failure). Dialysis services include routine laboratory tests, machine use and/or the injection of medication by a licensed physician. It also includes dialysis-related supplies.

Limits:  Medicaid will only pay for dialysis services provided in a freestanding dialysis center and are limited to one treatment per recipient, per day, up to three times per week. Medicaid will pay for home peritoneal dialysis and is limited to one treatment per recipient, per day. Medicaid pays for the medication Erythropoietin (Epogen or EPO) and is limited to up to three times per week. The weekly maximum number of treatments may be exceeded if additional treatments are determined to be medically necessary by the recipient’s nephrologist (kidney disease doctor) or primary care physician.

Exceptions:  Medicaid does not cover any services other than hemodialysis (the removing of waste products and excess fluids from the blood) and the administering of the injectable medication Erythropoietin (Epogen or EPO) in a freestanding dialysis center, and home peritoneal dialysis supplies provided by a freestanding dialysis center.

Co-pays: None

Reform items that can vary: None

 

Benefit: Durable Medical Equipment

 

Definition: Durable medical equipment (DME) is equipment that can be used repeatedly, serves a medical purpose, and is appropriate for use in the patient’s home. Medical supplies are medical or surgical items that are consumable, expendable, disposable or non-durable, and are appropriate for use in the patient’s home. Medicaid covers for DME and medical supplies provided by Medicaid participating providers.
DME may be rented or purchased. Examples of reimbursable equipment and supplies include, but are not limited to:

  • Ambulatory equipment (canes, crutches, walkers);
  • Augmentative and assistive communication devices;
  • Blood glucose meters and strips;
  • Commodes;
  • Diabetic supplies;
  • Enteral nutrition (tube feeding) supplements when prior authorized;
  • Heparin Lock Flush Syringes;
  • Hospital type beds and accessories;
  • Insulin syringes;
  • Orthotics(foot or lower leg supporting device) and prosthetics (artificial extension of a missing body part);
  • Ostomy and urological supplies;
  • Oxygen and oxygen-related equipment;
  • Peak flow meters;
  • Suction pumps;
  • Urine Ketone Test Strips; and
  • Wheelchairs.

Medical necessity for DME or supplies must be documented by a prescription, a statement of medical necessity, a plan of care, or a hospital discharge plan. The documentation must be signed and dated by the attending physician and include specific information on the item needed, the duration of need, and the recipient’s diagnosis.

Limits: Limitations to Medicaid reimbursement for DME and medical supplies include:

  • Most medical supplies are limited to one per day, per recipient;
  • DME and supplies are not covered for recipients in a hospital, nursing facility or intermediate care facility for the developmentally disabled (ICF/DD)
  • Some DME services and medical supplies are reimbursable only for recipients 20 years of age or younger; and
  • Custom wheelchairs must be prior-authorized.

Exceptions:The following services may be reimbursed for beneficiaries 20 years of age or younger in nursing facilities or ICF/DD:

  • Some customized orthotics and prosthetics;
  • Customized wheelchairs; and
  • Augmentative and assistive communication devices for children 20 years of age or younger.

Co-pays: None

Reform items that can vary: Dollar limits may be imposed; however limits do not apply to orthotics (foot or lower leg supporting device) and prosthetics (artificial extension of a missing body part) over $3,000 and motorized wheelchairs.

 

Benefit: Emergency Room

 

Definition: Treatment at an emergency room when a PCP is not available or for a life threatening condition such as severe wounds, head trauma, automobile accident injuries, or breathing difficulties, heart attacks or strokes.

Limits: None

Exceptions: None

Co-pays: None unless determined to be a non-emergency, then there is a 5 percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive non-emergency services not to exceed $15.00, unless exempt.

Reform items that can vary: None

 

Benefit: Hearing Services

 

Definition: Florida covers hearing services provided by licensed, Medicaid participating Ear, Nose and Throat doctors, audiologists (healthcare professional specializing in identifying, diagnosing, treating and monitoring hearing disorders), and hearing aid specialists.  Medicaid hearing services include:

  • Cochlear implant services (a surgically implanted electronic device or bionic ear);
  • Diagnostic testing;
  • Hearing aids (evaluations, fitting and dispensing, repairs and accessories); and
  • Newborn hearing screening.( Newborn hearing screening must be performed in the hospital or birthing center)

Limits: 

  • Medicaid reimbursement for evaluations is limited to one every three years from the date of service (Date of service for hearing aids is the day the hearing aid is ordered);
  • Hearing aids are limited to one per ear per recipient every 3 years;
  • Cochlear implants are limited to one in either ear, but not both. Cochlear implants must be prior authorized;
  • Medicaid does not reimburse for hearing aid routine maintenance; batteries, cord or wire replacement, or cleaning; and
  • Medicaid does not reimburse for hearing aid repairs until after the manufacturer’s warranty has expired.

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Home Health Services

 

Definition: Home health services are provided in a beneficiary’s home or other authorized setting to promote, maintain or restore health or to reduce the effects of illness and disability. Medicaid reimbursable services include:

  • Home visit services provided by a registered nurse or a licensed practical nurse;
  • Home visits provided by a qualified home health aide;
  • Private duty nursing;
  • Personal care services;
  • Therapy (occupational/physical therapy and speech-language problems) services; and
  • Medical supplies, appliances and durable medical equipment.

Limits:  Medicaid reimbursement for home health services must be determined medically necessary and also meet the following limitations:

  • Dually eligible Medicaid/Medicare recipients must receive Medicare reimbursable home health services from a Medicare-enrolled home health agency;
  • Nursing and home health aide visit services are limited to:
    • A total of four visits by nurses and/or aides per day, per recipient, and
    • A total of 60 visits by nurses and/or aides per lifetime, per recipient, without precertification;
  • Private duty nursing, personal care and therapy services are limited to children 20 years of age or younger who are medically complex. Private duty nursing and personal care services must be prior authorized by Medicaid or its authorized agent; and
  • Private duty nursing and personal care services are limited to:
    • Two to 24 hours of private duty nursing per day, per recipient; and
    • Two to 24 hours of personal care provided by home health aides per day, per recipient.

 

Exceptions:  Exceptions to the 60-visit limit for children and adults must be requested through the Medicaid reviewing agency. Prior authorization requests should be submitted before services are provided.

Co-pays: $2 copay for home health services, per provider, per day, unless exempt.

Reform items that can vary: Number of visits, dollar limits or copays may vary.

 

Benefit: Hospital Services:Inpatient

 

Definition: An inpatient is someone who is "admitted" to the hospital and stays overnight or for an indeterminate time, usually several days or weeks. Florida covers inpatient services provided under the direction of a licensed physician or dentist. Inpatient hospital services includes:

  • room and board,
  • medical supplies,
  • diagnostic and therapeutic services,
  • use of hospital facilities,
  • medications and biological tests,
  • nursing care, and
  • all supplies and equipment necessary to provide the appropriate care and treatment of patients.

Limits:  Medicaid coverage for inpatient hospital care for adults age 21 and older is limited to 45 days per state fiscal year (July 1 through June 30). There is no limit on the number of days for recipients 20 years old or younger.

Admissions for hospital inpatient services must be prior authorized. However, certain categories of recipients and circumstances are exempt from the prior authorization requirement. For example, some recipient exemptions are as follows:

  • those enrolled in a HMO or PSN;
  • Dual eligibles for both Medicare and Medicaid; and

those enrolled in the Children’s Medical Service (CMS) Network.

Exceptions:Medicaid will reimburse inpatient hospital services to a non-Medicaid-participating hospital in an emergency, for the duration of the emergency.  Medicaid will not reimburse a recipient in the Presumptively Eligible Pregnant Women (PEPW) program. They are not eligible for services associated with labor, delivery, postpartum, and inpatient hospitalization.

Co-pays: $3.00 per admission unless the recipient is exempt.

Reform items that can vary: Co-pays.

 

Benefit: Hospital Outpatient Surgery

 

Definition: An outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or facility for diagnosis or treatment. Treatment provided in this fashion is called ambulatory care.

Limits: Medicaid coverage for outpatient hospital services is limited to $1,500 per recipient, per state fiscal year (July 1 through June 30) for recipients who are age 21 and older. There is no reimbursement limitation for children 20 years of age or younger.

Exceptions: Exceptions to the outpatient fiscal year limitation are made for surgical procedures performed in an outpatient setting, infant delivery, chemotherapy services, and dialysis services. Examples of outpatient surgery are: cataract surgery, myringotomy with insertion of tube, single mastoidectomy, ligation and stripping of varicose lower limb veins, inguinal hernia repair, tubal ligation, ligation of vas deferens, and dilation and curettage.

Medicaid will reimburse outpatient hospital services furnished by a non-Medicaid participating hospital in an emergency, for the duration of the emergency.

Co-pays: $3 for each hospital outpatient or clinic visit unless exempt. Also there is a five percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive non-emergency services not to exceed $15.00, unless the recipient is exempt.

Reform items that can vary: None

 

Benefit: Lab / X-ray

 

Definition:  A laboratory is a place where tests are done to get information about the health of a patient. An x-ray is a picture of something such as a bone, joint, muscle or organ to determine a medical condition. Laboratory and x-ray services are performed in several settings, e.g., inpatient hospital, outpatient hospital, clinic and doctor’s office.

Limits:  Laboratory -- The frequency of some tests is limited.
X-ray: -- Medicaid reimbursement for portable x-ray services is limited to one unit of service, per procedure, per recipient, per day.

Exceptions:  Laboratory Exceptions:  The frequency limitations for certain procedure codes may be exceeded based on diagnosis codes.

Co-pays: Labs: There is a $1 beneficiary co-payment for independent laboratory services, per provider, per day, unless the beneficiary is exempt.

Reform items that can vary: None

 

Benefit: Maternity / Family Planning Services

 

Definition:
Birth Centers/ Midwife Services are provided at facilities and provide obstetrical (medical care involving a woman and her baby during pregnancy, childbirth and the period shortly after birth), gynecological (medical care involving the female reproductive organs) and family planning services (see definition below).

Medicaid reimburses maternity services for:

  • pre-birth family planning services;
  • Gynecological services;
  • Initial comprehensive and prenatal examinations;
  • Labor management for beneficiaries who transfer to a hospital;
  • Newborn assessment;
  • Post delivery examinations;
  • Post delivery recovery;
  • Related pregnancy services; and
  • Normal delivery.

Family planning services include educational, medical or social activities to help someone, including minors, to determine freely the number and spacing of their children, to learn about sexually transmitted diseases, and birth control.

Limits:  Birth Centers -- Medicaid reimbursement for birth center services is limited to:

  • One family planning comprehensive visit, per year, per recipient;
  • One ultrasound per pregnancy;
  • Ten prenatal visits per recipient per pregnancy;
  • Two postpartum visits, which include an examination of both mother and baby; and
  • One newborn assessment.

Post delivery recovery at the birth center is limited to 24 hours.
Licensed Midwife Services: Medicaid reimburses –

  • One visit, per day, per recipient.
  • 10 prenatal visits per recipient per pregnancy
  • 2 postpartum visits per recipient per pregnancy.
  • Newborn assessments are limited to one per recipient.

Exceptions: None

Co-pays: Birth Center: There is a $2 beneficiary co-payment for gynecological services, per provider, per day, unless the recipient is exempt.
Licensed Midwife Services: None

Reform items that can vary: None

 

Benefit: Mental Health Services

 

Definition: for the purpose of improving an individual's mental health or to treat a mental illness. Mental health services are provided in several settings, for example, community mental health clinic, outpatient hospital and physician office. The services may also be provided to minors by school psychologists.  An additional benefit is mental health targeted case management services. The purpose of mental health targeted case management is to assist recipients in gaining access to needed medical, social, educational, and other services.

Limits:  Medicaid will reimburse:

  • Up to 344 units (15 minutes equals one unit) of mental health targeted case management services per month, per recipient; and
  • Up to 48 units of intensive team services per recipient, per day.

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Outpatient Hospital Services (non-emergency)

 

Definition: Outpatient hospital services are provided by a doctor or dentist at a licensed Medicaid hospital or clinic for preventive, diagnostic, therapeutic or palliative (treatment that may reduce the severity of disease symptoms) care and service items that are scheduled and don’t require an overnight stay.

Medicaid covers supplies, nursing care, therapy and medications. Primary care services such as regular checkups or visits to a PCP provided in an outpatient hospital setting, hospital-owned clinic or satellite facility are not considered outpatient hospital services.

Limits:  Medicaid coverage for outpatient hospital services is limited to $1,500 per recipient, per state fiscal year (July 1 through June 30) for recipients who are age 21 and older. There is no reimbursement limitation for children 20 years of age or younger.

Exceptions:  Exceptions to the $1,500 limit are made for the surgical procedures that are performed in an outpatient setting for child delivery, chemotherapy services, and dialysis services.

Co-pays: $3 per visit unless the recipient is exempt.
Co-insurance: There is a 5 percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive non-emergency services not to exceed $15.00, unless the recipient is exempt.

Reform items that can vary: None

 

Benefit: Outpatient Therapy (physical / respiratory / occupational / speech)

printer friendly version Print

Definition: Physical therapy (PT) addresses the development, improvement or restoration of muscles or relief of muscular pain. PT also is used to relearn body functions or improve a person’s posture to attain maximum movement and relief from pain.

Respiratory therapy is the evaluation and treatment of breathing disorders.

Occupational therapy assists people who have difficulty in achieving a healthy and balanced lifestyle. Occupational therapy gives people the "skills for the job of living" necessary for living meaningful and satisfying lives.

Speech therapy involve the evaluation and treatment of speech-language disorders.

Limits: Medicaid reimbursement is limited to:

  • One initial evaluation per recipient, per provider; and
  • One re-evaluation every six months per recipient, per provider.

All therapy treatments must have a minimum duration of 15 minutes (one unit) of face-to-face contact between the recipient and the therapist with a maximum of 14 units of service per week. Daily treatment may not exceed 4 units-of-service.

The recipient’s primary care physician must prescribe all therapy treatments.

Speech Therapy Only: A group speech-language therapy treatment is limited to six children. The group must receive a minimum of 30-minutes of therapy.

Exceptions:  None

Co-pays: None

Reform items that can vary: None

 

Benefit: Pharmacy

Definition: Medications prescribed by a physician to cure a disease or illness or prevent an infection. Medicaid covers most medications used in outpatient settings, including injectable drugs. Most medications included on the Medicaid Preferred Drug List (PDL) are available without prior authorization (PA). Medications not on the PDL require PA.

Limits:  Medicaid does not reimburse pharmacies for the following products:

  • Anorectics (unless prescribed for an indication other than obesity)
  • Cough and cold combination medications for recipients age 21 and older
  • DESI ineffective drugs as designated by the Centers for Medicare and Medicaid Services (CMS)
  • Drugs for patients who are hospitalized or being treated in outpatient hospital facilities or ambulatory surgical centers
  • Drugs to treat the terminal condition of hospice recipients
  • Drugs used to treat infertility
  • Experimental drugs
  • Erectile Dysfunction Drugs
  • Hair growth restorers and other drugs for cosmetic use
  • Immunizations fornon-Child Health Check-Up recipients 21 years of age and older, except for influenza and pneumoccas vaccines for institutionalized recipients
  • Prostheses, appliances and devices (except products for diabetics and products used as contraceptives)
  • Vitamins (except prenatal vitamins for pregnant and lactating women and folic acid as a single entity; one vitamin or vitamin/mineral prescription monthly for dialysis patients, fluoridated pediatric vitamins for children 12 years of age or younger); and prescribed ferrous sulfate, gluconate, or fumarate for non-institutionalized patients (ferrous sulfate, gluconate, or fumarate if they are available as floor stock to institutionalized patients) and
  • All other over-the-counter products not specified above

Drugs must be prescribed for medically accepted indications.

Medicaid does not reimburse for drugs not included in a manufacturer’s rebate agreement. Drugs must be prescribed for medically accepted indications.

PA is required for Actiq®, albumin, Aranesp®, Botox®, Cytogam®, Fuzeon®, growth hormone for adults with growth hormone deficiency, immune globulins, Leukine®, Neupogen®, Neurontin®, Neulasta®, Neutrexin®, Orfandin®, Oxycontin®, Panretin®, Proleukin®, Provigil®, Procrit®, Serostim®, Targretin® gel and capsules, Regranex® in long-term care facilities, Vfend®, Valycte®, Xenical®, Venofer®, and adult human growth hormone for HIV/AIDS. HIV/AIDS medications are exempt from PDL restrictions.

PA is required for all prescribed drugs that are not on the PDL. Anti-retrovirals for HIV/AIDS are exempt from PDL restrictions.

Medicaid processes all prescription claims through Drug Utilization Review (DUR) and will not reimburse for prescriptions that are refilled too often or too soon, that duplicate other prescriptions, or that result in excessively high dosages for the recipient.

Exceptions:  A provider must request and receive authorization for all exception drugs not on the PDL.

Co-pays: None

Reform items that can vary: # of RX; total annual amount; and plans may vary the medications allowed. Beneficiaries who suffer from chronic conditions may need to verify that the medications they use to treat or manage their health condition are included in a health plan’s formulary (list of authorized medications).

 

Benefit: Podiatrist

 

Definition: A doctor who specializes in disorders of the foot, ankle, knee, leg and hip (collectively known as the lower extremity).

Limits:  Podiatry services are limited to:

  • One podiatrist-recipient contact per day, not to exceed two per month (except for emergencies);
  • One long-term care or custodial care facility service per month, per recipient, per provider or provider group (except for emergencies) with a referral from the recipient’s attending physician; and
  • One new patient evaluation and management service per recipient, every three years, if no services were rendered by the podiatrist to the recipient during the three years. Subsequent encounters must be reimbursed as established patient evaluation and management services.

All elective surgical procedures require prior authorization, except for recipients 20 years of age or younger who have been screened in the Child Health Check-Up program within 12 months of the date of surgery.

Recipients are able to receive up to four podiatry visits without authorization from their MediPass provider.

Exceptions: None

Co-pays: There is a $2 beneficiary co-payment for podiatry services, per provider, per day, unless the recipient is exempt.

Reform items that can vary: None

 

Benefit: Primary Care Physician (PCP)

 

Definition:  The doctor who manages the overall care of a patient by performing services to treat a particular injury, illness, or disease. The PCP also provides referrals to specialist when the scope of care is beyond the PCP’s training.

Limits:  Medicaid reimbursement for physician services is limited to:

  • One physician-recipient contact per provider specialty, per day (except for emergencies);
  • One long-term care facility service per physician, per month, per recipient (except for emergencies);
  • One physician consultation per 365 days, per physician of any specialty, per recipient (for non-hospitalized Medicaid recipients);
  • Ten prenatal visits per recipient per pregnancy. Additional visits, up to 14, may be reimbursed for high risk pregnancies. Two medically necessary postpartum visits per recipient per pregnancy; and
  • One new patient evaluation and management service per physician specialty, every three years, if no services were rendered by the physician to the recipient during the prior three years. Subsequent encounters must be reimbursed as established patient evaluation and management services.

Medicaid does not reimburse cosmetic surgery or experimental or investigational procedures.

Eye exams are reimbursable only if related to reported vision problems, illness, disease or injury.

Elective surgery performed within the inpatient hospital setting must be medically necessary and prior authorized, except for recipients 20 years of age or younger who have been screened in the Child Health Check-Up program within 12 months prior to the date of surgery.

Medicaid does not reimburse abortions except for one of the following reasons:

  • The woman suffers from a physical disorder, physical injury or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would place the woman in danger of death unless an abortion is performed;
  • The pregnancy is the result of incest; or
  • The pregnancy is the result of rape.

Exceptions: None

Co-pays: $2 for physician services, per provider, per day, unless exempt.

Reform items that can vary: Co-pays

 

Benefit: Advanced Registered Nurse Practitioner (ARNP)

 

Definition:An ARNP is a registered nurse who has completed specific advanced nursing education (generally a master's degree) and training in the diagnosis and management of common as well as complex medical conditions. ARNPs treat both general and chronic conditions through comprehensive history taking, physical exams, prescribing medications, physical therapy, ordering tests and therapies for patients, within their scope of practice. Many ARNPs can write prescriptions. ARNPs must work in collaboration with a doctor.

Limits:  Medicaid reimbursement for ARNP services is limited to:

  • One ARNP-recipient contact per day (except for emergencies);
  • One long-term care facility service, per ARNP, per month, per recipient (except for emergencies);
  • Ten prenatal visits per recipient per pregnancy. Two postpartum visits per recipient per pregnancy; and
  • One new patient evaluation and management service per physician assistant, per recipient every three years, if no services were rendered by the physician assistant to the recipient during the three years. Subsequent encounters must be reimbursed as established patient evaluation and management services. An additional new patient visit cannot be done by the supervising doctor of the ARNP for a patient already seen as a new patient by an ARNP.

Exceptions: None

Co-pays: $2 for ANRP services, per provider, per day, unless exempt.

Reform items that can vary: Co-pays

 

Benefit: Physician Assistant (PA) services

 

Definition: PAs are medically trained and licensed health care providers who practice medicine with a doctor’s supervision. PAs perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, interpret diagnostic tests, refer patients to specialists when appropriate and assist in surgery. PAs may practice in any medical or surgical specialty.

Limits:  Medicaid reimbursement for physician assistant services is limited to:

  • One physician assistant-recipient contact per day (except for emergencies);
  • One long-term care facility visit per month, per recipient (except for emergencies); and
  • One new patient evaluation and management service per physician assistant, per recipient every three years, if no services were rendered by the physician assistant to the recipient during the three years. Subsequent encounters must be reimbursed as established patient evaluation and management services. An additional new patient visit cannot be done by the supervising doctor of the PA for a patient already seen as a new patient by a physician assistant.

Medicaid cannot reimburse a physician assistant and a physician for the same procedure, same recipient, and same date of service. Medicaid may reimburse a surgeon for a surgical service and a physician assistant for the assist-at-surgery service.

Exceptions: None

Co-pays: $2 for PA services, per provider, per day, unless exempt.

Reform items that can vary: Co-pays

 

Benefit: Specialty Physician (Specialist)

 

Definition: A doctor or surgeon who continued medical training beyond a general medical degree and specialized in a specific area of medicine such as surgery, internal medicine, diagnostic or neurological.

Limits:  Medicaid reimbursement for physician services is limited to:

  • One physician-recipient contact per provider specialty, per day (except for emergencies);
  • One long-term care facility service per physician, per month, per recipient (except for emergencies);
  • One physician consultation per 365 days, per physician of any specialty, per recipient (for non-hospitalized Medicaid recipients);
  • Ten prenatal visits per recipient per pregnancy. Additional visits, up to 14, may be reimbursed for high risk pregnancies. Two medically necessary postpartum visits per recipient per pregnancy; and
  • One new patient evaluation and management service per physician specialty, every three years, if no services were rendered by the physician to the recipient during the prior three years. Subsequent encounters must be reimbursed as established patient evaluation and management services.

Medicaid does not reimburse cosmetic surgery or experimental or investigational procedures.

Eye exams are reimbursable only if related to reported vision problems, illness, disease or injury.

Elective surgery performed within the inpatient hospital setting must be medically necessary and prior authorized, except for recipients 20 years of age or younger who have been screened in the Child Health Check-Up program within 12 months prior to the date of surgery.

Medicaid does not reimburse abortions except for one of the following reasons:

  • The woman suffers from a physical disorder, physical injury or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would place the woman in danger of death unless an abortion is performed;
  • The pregnancy is the result of incest; or
  • The pregnancy is the result of rape.

Exceptions: None

Co-pays: $2 for physician services, per provider, per day, unless exempt.

Reform items that can vary: Co-pays

 

Benefit: Therapy (physical / respiratory / occupational / speech)

 

Definition: Physical therapy addresses the development, improvement or restoration of muscles. PT also is used to relearn body functions or improve a person’s posture to attain maximum movement and relief from pain.

Respiratory therapy is the evaluation and treatment of breathing disorders.

Occupational therapy assists people who have difficulty in achieving a healthy and balanced lifestyle. Occupational therapy gives people the "skills for the job of living" necessary for living meaningful and satisfying lives.

Speech therapy involves the evaluation and treatment of speech-language disorders.

Limits:  Medicaid reimbursement is limited to:

  • One initial evaluation per recipient, per provider; and
  • One re-evaluation every six months per recipient, per provider.

All therapy treatments must have a minimum duration of 15 minutes (one unit) of face to face contact between the recipient and the therapist with a maximum of 14 units of service per week. Daily treatment may not exceed 4 units-of-service.

The recipient’s primary care physician must prescribe all therapy treatments.

Speech Therapy Only: A group speech-language therapy treatment is limited to six children. The group must receive a minimum of 30-minutes of therapy.

Exceptions: None

Co-pays: None

Reform items that can vary: None

 

Benefit: Transplant Services Organ and Bone Marrow

 

Definition: Bone marrow transplants are performed for the treatment of certain types of cancers and when the bone marrow fails to produce enough red/white blood cells and platelets; organ transplants are performed when an organ fails because of illness.

Acceptance as a candidate for covered transplant services is determined by the designated transplant hospital, not by Medicaid. Pre-transplant and post-transplant care, including medications, are covered by Medicaid even if the transplant is not a Medicaid covered transplant.

Limits:  Medicaid reimbursement for transplant services has the following limitations:

  • All out-of-state transplant referrals for organ and bone marrow transplants must be requested by a Medicaid designated transplant center. The prior authorization must be forwarded to the Medicaid office for review;
  • Out-of-state evaluations and transplants are not covered if the services are available in the state of Florida;
  • Physician services limitations apply; (see that benefit above)
  • Recipients age 21 and older are eligible for kidney, cornea, liver, lung, heart and bone marrow transplants when medically necessary and appropriate; and
  • Recipients 20 years of age or younger are eligible for transplants determined medically necessary and appropriate.

Adult heart, liver and lung transplants, and pediatric lung transplants require prior authorization. Medicaid does not reimburse transplant procedures that are deemed investigational or those not yet proven clinically effective as determined by consultants within the Agency Organ Transplant Advisory Council.

Exceptions: Medicaid reimburses for pre-transplant and post-transplant related services even if the transplant itself is not a covered service.
Medicaid does not reimburse for donor services for solid or bone marrow transplant procedures even if the donor is a Medicaid eligible recipient.

Co-pays: None

Reform items that can vary: None

 

Benefit: Transportation Non-emergency (NEMT)

 

Definition: Transportation for any beneficiary, personal care attendant or escort, if required, who have no other means of transportation available to any medically necessary Medicaid-compensable service for the purpose of receiving treatment, medical evaluation, or therapy. NEMT services do not include ambulance transportation.

Medicaid NEMT services are provided by the Florida Commission for the Transportation Disadvantaged, certain Reform Health Maintenance Organizations (HMO) and Reform Provider Service Networks (PSN).

Limits:  NEMT services are available only to eligible recipients who cannot obtain transportation on their own through any available means such as family, friends or community resources.
NEMT services are scheduled through the Community Transportation Coordinator (CTC) in each county under contract with the Commission for the Transportation Disadvantaged.  All transportation must be the most cost-effective and most appropriate method of transportation available.

Exceptions: Recipients who are enrolled in a Medicaid HMO or PSN that provides transportation in its scope of services must obtain all Medicaid transportation through the HMO’s or PSN’s network of transportation providers. If the HMO or PSN does not provide NEMT services, then transportation is arranged through the Community Transportation Coordinator in the recipient’s county of residence.

Co-pays: There is a $1 beneficiary co-payment for transportation services for each one-way trip, unless the beneficiary is exempt. Round trips require two co-pays or $2.

Reform items that can vary: Co-pays

 

Benefit: Vision Services

 

Definition: Visual services are provided by a licensed, Medicaid participating eye doctor. Visual services include eyeglasses, eyeglass repairs as required, glass eyes, and contact lenses.

Limits:  Contact lenses are limited to recipients who have unilateral aphakia (the absence of the lens of the eye, due to surgical removal, a perforating wound or ulcer, or congenital anomaly) or bilateral aphakia; and Eyeglasses are limited to no more than two pairs of eyeglasses per recipient, per 365 days, based on medical necessity as determined by a medical professional. All special eyeglasses and contact lenses must be prior authorized.

Exceptions:  None

Co-pays: None

Reform items that can vary:  total annual amount and copays may vary