Member Services: 1-844-243-5187 (TTY use 711) Available 8am - 7pm Monday - Friday | Language Assistance

Miami Children's Health Plan Offers Benefits and Programs to Help You and Your Family Live Better.


Coverage for Kids and Adults, Close to Home

 

You deserve to get the most from your benefits. Miami Children's Health Plan offers your standard Medicaid benefits and services. We also offer extra benefits at no cost to you. Because we are not just here to take care of you when you are sick.  We are here to help you live better.

Learn about some of the many benefits you get as a Miami Children's Health Plan Member.
 

Service

Description (including limits)

Prior Authorization Required

Phone Number

General Expanded Benefits

Circumcision
(newborns only)

One per lifetime for infants up to 28 days old

No prior authorization
is required

 

Home Delivered Meals

Up to ten (10) meals following an enrollee’s discharge from a hospital or nursing facility; benefit is limited to four hospital nursing facility admissions per year

Prior authorization
is required

(844)-824-8768

Meal Stipend (available for long distance medical appointment day-trips)

$100 per day for up to 21 days for enrollees and their families. Includes up to two (2) meals per day. This benefit is covered only if traveling greater than 100 miles from enrollee's home.

Prior authorization
is required

(877)-611-3446

Over-the-Counter Benefit

$25/month to spend on an approved list of products

No prior authorization
is required

 

 

Service

Description (including limits)

Prior Authorization Required

Phone Number

Adult Expanded Benefits

Chiropractic Services

4 established patient visits per year, in addition to the state benefit of 24

No prior authorization
is required

 

Computerized Cognitive Behavioral Therapy

Unlimited visits for health and behavior assessment and re-assessment; individual, group, and family (with or without the patient present) health and behavior intervention

No prior authorization
is required

 

Hearing Services

The following services are provided 1 per every 2 years: assessment for hearing aids, hearing aid fitting/checking, hearing aid monaural in ear, behind ear hearing aid, hearing aid dispensing fee, in ear binaural hearing aid, behind ear binaural hearing aid, dispensing fee, behind ear cros hearing aid, cros hearing aid dispensing fee, behind ear bicros hearing aid, dispensing fee bicros, and hearing evaluation

No prior authorization
is required for hearing assessments;


Hearing Aids require
prior authorization

 

Occupational Therapy

One evaluation and one
re-evaluation per year, and up to 7 therapy treatment units per week

No prior authorization
is required for initial evaluation

 

Prior authorization is required for subsequent visits thereafter

 

Physical Therapy

One evaluation and one
re-evaluation per year, and up to 7 therapy treatment units per week

No prior authorization is required for initial evaluation

 

Prior authorization is required for subsequent visits thereafter

 

Prenatal Services

Rental of a hospital grade breast pump, one per year with prior authorization; rental of a breast pump, one per two years;
14 antepartum visits for
low-risk pregnancies;
18 antepartum visits for high-risk pregnancies;
3 postpartum visits within
90 days following delivery

Prior authorization is required for Hospital Grade Breast Pump 

 

No prior authorization
required for Breast Pump rental

(855)-481-0505

Primary Care Services

Unlimited outpatient visits

No prior authorization
is required

 

Respiratory Therapy

One initial evaluation and one re-evaluation per year; one respiratory therapy visit per day

No prior authorization

is required for initial evaluation

 

Prior authorization is required for subsequent visits thereafter

 

Speech Therapy

One evaluation and
re-evaluation per year;
one evaluation of oral
an pharyngeal swallowing function per year; up to
7 therapy treatment units per week; one AAC initial evaluation and one AAC
re-evaluation per year;
up to four 30-minute AAC fitting, adjustment, and training sessions per year

No prior authorization
is required for initial evaluation

 

Prior authorization is required for subsequent visits thereafter

(844)-824-8768

Vaccine – Influenza

One vaccination per enrollee per year

No prior authorization
is required

 

Vaccine – Pneumonia

Pneumococcal vaccines for enrollees 21+…1 vaccine every 5 years

No prior authorization
is required

 

Vaccine – Shingles

Based on CDC ACIP guidelines for age 21 and over (2 doses, 2 to 6 mos apart. Max total 2 per member lifetime)

Yes, for enrollees ages
18-49 due to limited risk factors

 

No, for enrollees ages 50 and older

(844)-824-8768

Vision Services

1 pair of frames per year, one eye exam per year. The following contact lenses are dispensed in a 6-month supply with a prescription: PMMA, toric or prism ballast, per lens; gas permeable, toric, prism ballast, per lens; gas permeable, extended wear, per lens, hydrophilic, spherical, per lens, hydrophilic, toric, or prism ballast, per lens, hydrophilic extended wear, per lens; contact lens, other type

No prior authorizations are required for vision services

 

Waived Copayments

All services that have a copayment requirement
in accordance with
Rule 59G-1.056, FAC

Not Applicable

 

CVS Discount Program

20% discount off certain OTC items – CVS brands only

No prior authorization
is required

 

Home Health Nursing/Aide Services

  • Home health aide or certified nurse assistant, providing care in the home; per hour.Nursing care, in the home; by a licensed practical nurse, per hour
  • Nursing care, in the home; by a licensed practical nurse, per hour
  • Personal Care Service
    Per 15 Min
  • Personal Care Services, Per Diem
  • Home Health Aide Or Certified Nursing Aide,
    Per Visit
  • Registered Nurse Home Care, Per Diem
  • Licensed Practical Nurse, Home Care, Per Diem

Prior authorization
is required

(855)-481-0505

Prenatal Vaccine – TdaP

Tetanus diphtheria toxoids acellular pertussis vaccine (TDaP) intramuscular

No prior authorization
is required

 

Cellular Phone Services

1 cellphone; 350 minutes; unlimited text messages;
1 GB data; 1 per household every 2 years

No prior authorization
is required

 

Medication Assisted Treatment

Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program)

Prior authorization
is required

(888)-710-2313

Medically Related Home Care Services

2 carpet cleanings per year for adults in Asthma Disease program

Prior authorization
is required

(844)-824-8768

Therapy – Art

Activity therapy, such as music, dance, art, or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session
(45 minutes or more)

Prior authorization
is required

(844)-824-8768

Therapy – Pet

Activity therapy, such as music, dance, art, or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session
(45 minutes or more)

Prior authorization
is required

(844)-824-8768

 

COVERED HEALTH MANAGEMENT PROGRAMS

Miami Children’s Health Plan offers programs to help members access care and learn how to manage health conditions, including case management. The following are health management programs available to members. For more information please contact Miami Children’s Health Plan at (844)-243-5187

Program Name

Description

Contact Information

Complex Care Program

Program for Pediatrics and Adults that focuses on advances illness and/or multiple comorbid disease states

(844)-243-5187

Condition Care Health Education

Program for Pediatrics and Adults that focuses on a specific disease state and provides education

(844)-243-5187

Diabetes Self-Management Education

Available to members with Type
1 diabetes

(844)-243-5187

Maternity Care

Program for expectant mothers
to ensure access to prenatal care and education

(844)-243-5187

Smoking Cessation

Healthy Behavior program providing a combination of medication and counseling to
help the member quit smoking (90-120 day program)

(844)-243-5187

Substance Use Recovery Program

Healthy Behavior program focusing on addressing needs of members with an existing substance use issue or diagnosis (90-120 day program)

(844)-243-5187

Transitional Care Program

Program focused on reducing avoidable readmissions for members at high risk of readmission from an acute facility

(844)-243-5187

Weight Management

Healthy Behavior program focusing on weight management, healthy diet, and exercise led by
a Health Educator
(90-120 day program)

(844)-243-5187

Right Care Right Time

Emergency Room diversion program to educate members on appropriate levels of care, connect members to primary care, and prevent avoidable ER utilization

(844)-243-5187

Special Health Care Needs (SHCN)

Care management program to address individuals with special health care needs to include Early Intervention Services, Medical Foster Care, and other unique healthcare needs

(844)-243-5187

Catastrophic Care

Program focused on managing members with complex healthcare needs. The focus is on stabilizing members and their disease process through coordination with primary care and required specialist to encourage appropriate utilization and optimal healthcare outcomes.

(844)-243-5187

 

 


 

Standard Medicaid Benefits


Service Description Coverage/Limitations Prior Authorization

Addictions Receiving Facility Services

Services used to help people who are struggling with drug or alcohol addiction

As medically necessary and recommended by us

Prior authorization is required

Allergy Services

Services to treat conditions such as sneezing or rashes that are not caused by an illness

We cover blood or skin allergy testing and up to 156 doses per year of allergy shots

Prior authorization is required

Ambulance Transportation Services

Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities

Covered as medically necessary.

Prior authorization is required for Non-Emergent Ground Medical Transport and all Air Medical Transport

Ambulatory Detoxification Services

Services provided to people who are withdrawing from drugs or alcohol

As medically necessary and recommended by us

Prior authorization is required

Ambulatory Surgical Center Services

Surgery and other procedures that are performed in a facility that is not the hospital (outpatient)

Covered as medically necessary.

Certain outpatient surgeries require prior authorization. Call 1-844-243-5187 for more information.

Anesthesia Services

Services to keep you from feeling pain during surgery or other medical procedures

Covered as medically necessary.

All inpatient and elective admissions require prior authorization.

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

No prior authorization is required

Behavioral Health Assessment Services

Services used to detect or diagnose mental illnesses and behavioral health disorders

We cover:

- One initial assessment per year

- One reassessment per year

- Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)

No prior authorization is required

Behavioral Health Overlay Services

Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program

We cover 365/366 days of services per year, including therapy, support services and aftercare planning

Prior authorization is required.

Behavioral Health Services – Child Welfare

A special mental health program to children enrolled in a DCF program

As medically necessary and recommended by us

Prior authorization is required

Cardiovascular Services

Services that treat the heart and circulatory (blood vessels) system

We cover the following as prescribed by your doctor:

- Cardiac testing

- Cardiac surgical procedures

- Cardiac devices

Certain Cardiovascular services may require prior authorization. Call 1-844-243-5187 for more information.

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

No prior authorization is required.

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

No prior authorization is required.

Clinic Services

Health care services provided in a county health department, federally qualified health center, or a rural health clinic

 

No prior authorization is required

Community-Based Wrap-Around Services

Services provided by a mental health team to children who are at risk of going into a mental health treatment facility

As medically necessary and recommended by us

Prior authorization is required

Crisis Stabilization Unit Services

Emergency mental health services that are performed in a facility that is not a regular hospital

As medically necessary and recommended by us

No prior authorization is 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 prior authorization is required

Drop-In Center Services

Services provided in a center that helps homeless people get treatment or housing

As medically necessary and recommended by us

Prior authorization is required

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 1-844-243-5187 for more information.

Certain DME services may require prior authorization. Call 1-844-243-5187 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

No prior authorization is required

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.

All air ambulance services require prior authorization (emergent requests may be submitted post-service).

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 year

- Child health check-ups 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 Prior authorization is required

Family Therapy Services

Services for families to have therapy sessions with a mental health professional

We cover:

- Up to 26 hours per year

No prior authorization is required

Family Training and Counseling for Child Development

Services to support a family during their child’s mental health treatment

As medically necessary and recommended by us

Prior authorization is required

Gastrointestinal Services

Services to treat conditions, illnesses, or diseases of the stomach or digestion system

We cover:

- Covered as medically necessary

Certain Gastrointestinal services may require prior authorization. Call 1-844-243-5187 for more information.

Genitourinary Services

Services to treat conditions, illnesses, or diseases of the genitals or urinary system

Covered as medically necessary

No prior authorization is required

Group Therapy Services

Services for a group of people to have therapy sessions with a mental health professional

We cover:

- Up to 39 hours per year

No prior authorization is required

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

Certain Hearing services require authorization. Call 1-844-243-5187 for more information.

Home Health Services

Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury

We cover:

- Up to 4 visits per day for pregnant recipients and recipients ages 0-20

- Up to 3 visits per day for all other recipients

Prior authorization is required

Hospice Services

Medical care, treatment, and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers

- Covered as medically necessary

Prior authorization is required

Individual Therapy Services

Services for people to have one-to-one therapy sessions with a mental health professional

We cover up to 26 hours per year

No prior authorization is required

Infant Mental Health Pre and Post Testing Services

Testing services by a mental health professional with special training in infants and young children

As medically necessary and recommended by us

Prior authorization is required

Inpatient Hospital Services

Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you

We cover the following inpatient hospital services based on age and situation:

- Up to 365/366 days for recipients ages 0-20

- Up to 45 days for all other recipients (extra days are covered for emergencies)

Inpatient admissions require prior authorization

Integumentary Services

Services to diagnose or treat skin conditions, illnesses or diseases

- Covered as medically necessary

Certain Integumentary services may require prior authorization. Call 1-844-243-5187 for more information.

Laboratory Services

Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases

- Covered as medically necessary

Certain Laboratory services may require prior authorization. Call 1-844-243-5187 for more information.

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 prior authorization is required

Medication Assisted Treatment Services

Services used to help people who are struggling with drug addiction

- Covered as medically necessary

No prior authorization is required

Medication Management Services

Services to help people understand and make the best choices for taking medication

- Covered as medically necessary

No prior authorization is required

Mental Health Partial Hospitalization Program Services

Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from mental illness

As medically necessary and recommended by us

Prior authorization is required

Mental Health Targeted Case Management

Services to help get medical and behavioral health care for people with mental illnesses

Covered as medically necessary

Prior authorization is required

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

No prior authorization is required

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

Prior authorization is required

Neurology Services

Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system

- Covered as medically necessary

Certain neurology services may require prior authorization. Call 1-844-243-5187 for more information.

Non-Emergency Transportation Services

Transportation to and from all your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles

We cover the following services for recipients who have no transportation:

- Out-of-state travel

- Transfers between hospitals or facilities

- Escorts when medically necessary

No prior authorization is required.

Nursing Facility Services

Medical care or nursing care that you get while living full-time in a nursing facility. This can be a short-term rehabilitation stay or long-term

- We cover 365/366 days of services in nursing facilities as medically necessary

Prior authorization is required.

Occupational Therapy Services

Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house

We cover for children ages 0-20 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 five years

We cover for people of all ages:

- Follow-up wheelchair evaluations, one at delivery and one 6-months later

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.

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

Certain Oral Surgery services may require prior authorization. Call 1-844-243-5187 for more information.

Orthopedic Services

Services to diagnose or treat conditions, illnesses or diseases of the bones or joints

- Covered as medically necessary

Certain Orthopedic services may require prior authorization. Call 1-844-243-5187 for more information.

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

Certain Outpatient Hospital services may require prior authorization. Call 1-844-243-5187 for more information.

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

Certain pain management services require prior authorization. Call 1-844-243-5187 for more information.

Partial Hospitalization Services

Services for people leaving a hospital for mental health treatment

As medically necessary and recommended by us

Prior authorization is required

Physical Therapy Services

Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition

We cover for children ages 0-20 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 year

We cover for people of all ages:

- Follow-up wheelchair evaluations, one at delivery and one 6-months later

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.

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

No prior authorization is required

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

Certain Prescribed Drug services require prior authorization. Call 1-844-243-5187 for more information.

Private Duty Nursing Services

Nursing services provided in the home to people ages 0 to 20 who need constant care

We cover up to 24 hours per day

Prior authorization is required.

Psychiatric Specialty Hospital Services

Emergency mental health services that are performed in a facility that is not a regular hospital

As medically necessary and recommended by us

No prior authorization is required.

Psychological Testing Services

Tests used to detect or diagnose problems with memory, IQ or other areas

We cover 10 hours of psychological testing per year

Prior authorization is required.

Psychosocial Rehabilitation Services

Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores

We cover up to 480 hours per year

Prior authorization is required.

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

Certain imaging services may require prior authorization. Call 1-844-243-5187 for more information.

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

Regional Perinatal Intensive Care Center Services may require prior authorization. Call 1-844-243-5187 for more information.

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 prior authorization is required

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

Certain Respiratory services may require prior authorization. Call 1-844-243-5187 for more information

Respiratory Therapy Services

Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease

We cover:

- One initial evaluation per year

- One therapy re-evaluation per 6 months

- Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)

No prior authorization required

Self-Help/Peer Services

Services to help people who are in recovery from an addiction or mental illness/p>

As medically necessary and recommended by us

Prior authorization is required

Specialized Therapeutic Services

Services provided to children ages 0-20 with mental illnesses or substance use disorders

We cover the following:

- Assessments

- Foster care services

- Group home services

No prior authorization is required

Speech-Language Pathology Services

Services that include tests and treatments 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 year

We cover the following services for adults:

- One communication evaluation per 5 years

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.

Statewide Inpatient Psychiatric Program Services

Services for children with severe mental illnesses that need treatment in the hospital

Covered as medically necessary for children ages 0-20

Prior authorization is required.

Substance Abuse Intensive Outpatient Program Services

Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders

As medically necessary and recommended by us

Prior authorization is required.

Substance Abuse Short-term Residential Treatment Services

Treatment for people who are recovering from substance use disorders

As medically necessary and recommended by us

Prior authorization is required.

Therapeutic Behavioral On-Site Services

Services provided by a team to prevent children ages 0-20 with mental illnesses or behavioral health issues from being placed in a hospital or other facility

We cover:

- Up to 9 hours per month

Prior authorization is required

Transplant Services

Services that include all surgery and pre- and post-surgical care

Covered as medically necessary

Prior authorization is required.

Visual Aid Services

Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes

We cover the following services when prescribed by your doctor:

- Two pairs of eyeglasses for children ages 0-20

- Contact lenses

- Prosthetic eyes

No prior authorization is required

Visual Care Services

Services that test and treat conditions, illnesses and diseases of the eyes

- Covered as medically necessary

Certain Visual Care services may require prior authorization. Call 1-844-243-5187 for more information.


The benefit information provided is a summary, not a complete list of all benefits. Call Member Services at 1-844-243-5187 or TTY at 711 if you have questions about your benefits.  

 

Member Handbook

Manual del Miembro

 

Member Contact Information


a. Miami Children’s Health Plan is a Managed Care Plan with a Florida Medicaid Contract.
b. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the Managed Care Plan.
c. Limitations, and/or restrictions may apply.
d. Benefits, formulary, pharmacy network may change