<Contact information> <Service Name> <Subcontractor Name> <Contact information> To report suspected cases of abuse, neglect, abandonment, or exploitation of children or vulnerable adults 1-800-96-ABUSE (1-800-962-2873) TTY: 711 or 1-800-955-8771 For Medicaid Eligibility 1-866-762-2237 TTY: 711 or 1-800-955-8771 To report Medicaid Fraud and/or Abuse or to file a complaint about a health care facility 1-888-419-3456 To request a Medicaid Fair Hearing 1-877-254-1055 1-239-338-2642 (fax) To file a complaint about Medicaid services 1-877-254-1055 TDD: 1-866-467-4970 To find information for elders 1-800-96-ELDER (1-800-963-5337) To find out information about domestic violence 1-800-799-7233 TTY: 1-800-787-3224 To find information about health facilities in Florida To find information about urgent care <Plan insert free text> For an emergency 9-1-1 Or go to the nearest emergency room
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. Ambulatory Detoxification Services Services provided to people who are withdrawing from drugs or alcohol As medically necessary and recommended by us Ambulatory Surgical Center Services Surgery and other procedures that are performed in a facility that is not the hospital (outpatient) Covered as medically necessary. Anesthesia Services Services to keep you from feeling pain during surgery or other medical procedures Covered as medically necessary. Assistive Care Services Services provided to adults (ages 18 and older) help with activities of daily living and taking medication We cover 365/366 days of services per year, Behavioral Health Assessment Services Services used to detect or diagnose mental illnesses and behavioral health disorders We cover: One initial assessment per year One reassessment per year Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day) Copayment: $2.00 per visit Behavioral Health Overlay Services Behavioral health services provided to children (ages 0 – We cover 365/366 days of services per year, including therapy, support services and aftercare planning
18) enrolled in a DCF program Behavioral Health Services – Child Welfare A special mental health program to children enrolled in a DCF program As medically necessary and recommended by us 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 Copayment: $2.00 per office visit Child Health Services Targeted Case Management Services provided to children (ages 0 - 3) to help them get health care and other services Your child must be enrolled in the DOH Early Steps program 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 year X-rays Copayment: $1.00 per visit Clinic Services Health care services provided in a county health department, federally qualified health center, or a rural health clinic Copayment: $3.00 per visit to a federally qualified health center or rural health clinic visit Services Services provided by a mental health team to children who are at risk of going into a mental health treatment facility As medically necessary and recommended by us
Crisis Stabilization Unit Services Emergency mental health services that are performed in a facility that is not a regular hospital As medically necessary and recommended by us No 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 Drop-In Center Services Services provided in a center that helps homeless people get treatment or housing As medically necessary and recommended by us Durable Medical Equipment and Medical Supplies Services Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches, and other items. Medical supplies are items meant for one-time use and then thrown away Some service and age limits apply. Call <Plan Insert Free Text> for more information. 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 3 screenings per year Up to 3 follow-up evaluations per year Up to 2 training or support sessions per week
care for people with mental illnesses Mobile Crisis Assessment and Intervention Services A team of health care professionals who provide emergency mental health services, usually in people’s homes As medically necessary and recommended by us MultiSystemic Therapy Services An intensive service focused on the family for children at risk of residential mental health treatment As medically necessary and recommended by us Neurology Services Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system Covered as medically necessary Copayment: $2.00 per office visit Non-Emergency Transportation Services Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles We cover the following services for recipients who have no transportation: Out-of-state travel Transfers between hospitals or facilities Escorts when medically necessary Copayment: $1.00 per each one-way trip ($2.00 to go to your doctor’s office and back home) 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 Copayment: See information on Patient Responsibility for copayment information Occupational Therapy Services Occupational therapy includes treatments that help We cover for children ages and for adults under the 20
you do things in your daily life, like writing, feeding yourself, and using items around the house $1,500 outpatient services cap: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years We cover for people of all ages: Follow-up wheelchair evaluations, one at delivery and one 6-months later 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 Copayment: $2.00 per office visit Orthopedic Services Services to diagnose or treat conditions, illnesses or diseases of the bones or joints Covered as medically necessary Copayment: $2.00 per office visit 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 year for recipients ages 21 and over Copayment: $15.00 or less for non-emergency services at an emergency room and $3.00 for all others Pain Management Services Treatments for pain that does not get better Covered as medically necessary. Some service limits may apply
after other services have been provided Copayment: $2.00 per visit Partial Hospitalization Services Services for people leaving a hospital for mental health treatment As medically necessary and recommended by us 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 and for adults under the $1,500 outpatient services cap: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years We cover for people of all ages: Follow-up wheelchair evaluations, one at delivery and one 6-months later Podiatry Services Medical care and other treatments for the feet We cover: Up to 24 office visits per year Foot and nail care X-rays and other imaging for the foot, ankle and lower leg Surgery on the foot, ankle or lower leg Copayment: $2.00 per office visit 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 Private Duty Nursing Services Nursing services provided in the home to people ages 0 to who need constant care We cover: Up to 24 hours per day Psychiatric Specialty Emergency mental health services that As medically necessary and recommended by us No
Hospital Services are performed in a facility that is not a regular hospital Psychological Testing Services Tests used to detect or diagnose problems with memory, IQ or other areas We cover: 10 hours of psychological testing per year Copayment: $2.00 per visit Psychosocial Rehabilitation Services Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores We cover: Up to 480 hours per year Copayment: $2.00 per visit 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 Copayment: $1.00 per portable x-ray visit; $2.00 per office visit 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 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. Respiratory Services Services that treat conditions, illnesses or diseases of the We cover: Respiratory testing Respiratory surgical procedures
<Insert address and phone number> Send you a letter with our reason and tell you about your rights if you disagree. If you do not agree with a decision we made about your services, you can ask for an Appeal You can: Write us, or call us and follow up in writing, within 60 days of our decision about your services. Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply. <Insert address and phone number> We will: Send you a letter within 5 business days to tell you we received your appeal. Help you complete any forms. Review your appeal and send you a letter within 30 days to answer you. If you think waiting for 30 days will put your health in danger, you can ask for an Expedited or “Fast” Appeal You can: Write us or call us within 60 days of our decision about your services. <Insert address and phone number> We will: Give you an answer within 48 hours after we receive your request. Call you the same day if we do not agree that you need a fast appeal, and send you a letter within 2 days. If you do not agree with our appeal decision, you can ask for a Medicaid Fair Hearing You can: Write to the Agency for Health Care Administration Office of Fair Hearings. Ask us for a copy of your medical record. Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply. **You must finish the appeal process before you can have a Medicaid Fair Hearing. We will: Provide you with transportation to the Medicaid Fair Hearing, if needed. Restart your services if the State agrees with you. If you continued your services, we may ask you to pay for the services if the final decision is not in your favor. Fast Plan Appeal