Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

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Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Florida (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes		Yes	Limited to procedures safely performed in ambulatory setting, as approved by CMS	Medicare payment rates adjusted by county wage index	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$2/day at Mental Health Clinic		1 encounter/day for primary or preventive care	Fee for service or prospective cost based rate for primary care	CN & MN
Federally Qualified Health Center Services
Yes	$3/day		1 encounter/day except mental health services limited to 26 encounters/year	On site: prospective cost based rate/encounter, Off-site: fee for service	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$3/admission	Non-emergency admissions	45 days/year	Prospective cost based per diem with limits, admissions for organ transplants paid a global fee	CN & MN
Outpatient Hospital Services
Yes	5% of payment up to $15/visit for non-emergency services in the ER, $3/visit for other services		$1,500/year for non-emergency services (excluding surgery)	Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	$2/day		Quantity and frequency limits vary by service	Capitated payment or fee for service	CN & MN
Rural Health Clinic Services
Yes	$3/day		1 encounter/day except mental health services limited to 26 encounters/year	On site: prospective cost based rate/encounter, Off-site: fee for service	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes				Fee for service at 80% of physician fee	CN & MN
Chiropractor Services
Yes	$1/day		24 visits/year	Fee for service	CN & MN
Dental Services
Yes	5% of payment for denture-related services		Limited to services to alleviate pain or infection or preparatory or related to dentures	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	$2/day for oral surgery			Fee for service	CN & MN
Nurse Midwife Services
Yes			10 prenatal visits/year, 2 postpartum visits/year, 2 home visits/year	Fee for service at 80% of physician fee	CN & MN
Nurse Practitioner Services
Yes	$2/day for office or outpatient hospital visit		1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/pregnancy and 2 postpartum visits/pregnancy	Fee for service at 80% of physician fee	CN & MN
Optometrist Services
Yes	$2/day		Eye exams limited to determining presence of disease or reported vision problem	Fee for service	CN & MN
Physician Services
Yes	$2/day for office or non-emergency outpatient hospital visit	Specified services	1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/pregnancy, 2 postpartum visits/pregnancy	Fee for service	CN & MN
Podiatrist Services
Yes	$2/day		Visit frequency limitations based on site of service, routine foot care covered only for specified systemic conditions	Fee for service	CN & MN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes		Specified drugs	Step therapy required for some drugs not on PDL	Lower of AWP-16.4% or WAC+4.75%, plus $4.23 dispensing fee for retail pharmacies or $4.73 dispensing fee for non-traditional pharmacies	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
Yes			Limited to services for provision of augmentative and assistive communication systems	Fee for service	CN & MN
Products and Devices
Dentures
Yes	5% of payment for dentures and specified related services	Partial dentures and replacement full dentures	1 full upper and/or lower partial or full denture/lifetime	Fee for service	CN & MN
Eyeglasses
Yes		Specified items	Eyeglasses, contact lenses and prosthetic eyes for specified medical conditions, 2 pair of eyeglasses/year	Fee for service	CN & MN
Hearing Aids
Yes			1 evaluation/3 years, 1 hearing aid/ear/3 years	Fee for service	CN & MN
Medical Equipment and Supplies
Yes		Specified med equipment and med supply items	Limitations vary by item	Fee for service or individually priced	CN & MN
Prosthetic and Orthotic Devices
Yes		Specified services or items		Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes	$1/non-emergency trip	Non-emergency transports		Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes	$1/trip each way	Yes	Limited to beneficiaries unable to arrange for medically necessary transportation through any other means	See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes	$1-$3 dependng on service	Specified services	Limitations vary depending on service and provider	Fee for service	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes	$1/day, including portable x-ray services		In-home portable x-ray services must be medically justified	Fee for service	CN & MN
Targeted Case Management
Yes			Quantity and frequency limits vary by service	Fee for service or contracted rate	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes			Services for the following populations: 1, 2, 3, 4, 5, 6 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	$2/day	Additional visits	4 nursing or home health aide visits/day up to 60/lifetime, therapies not covered, only specified med equipment and supplies covered	Fee for service	CN & MN
Hospice Care
Yes				Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes			See service-specific FN	Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes			15 hosp leave days/hospitalization, 30 therapeutic leave days/year	Prospective cost based per diem	CN
Inpatient Psychiatric Services, under age 21
Yes		Yes	LOS limited by state's utilization reiew authority and restricted to approved residential treatement facilities	Prospective cost based all-inclusive per diem	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes			15 hosp leave days/hospitalization, 45 therapeutic leave days/year, 30 infirmary leave days/year with each less than 16 days and with hosp leave not covered if immediately following infirmary leave, facility must have 95% occupancy rate to be paid	Prospective cost based per diem with limits	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes			8 hosp leave days/hospitalization, 16 therapeutic leave days/year	Prospective per diem by facility size and location, occupancy adjusted, with higher rates for heavy care residents, payment for leave days requires 95% occupancy rate in prior quarter	CN
Religious Non-Medical Health Care Institution and Practitioner Services
Yes			Practitioner services not covered	Prospective cost based per diem	CN & MN

Notes: This State has an approved Section 1115 Waiver from CMS under which it is implementing a complete reform of its Medicaid program. The reform was implemented initially in Broward and Duval counties on September 1, 2006 and requires certain Medicaid eligibility groups to enroll in and receive healthcare services from specified health plans. The plans are paid a risk-adjusted premium and are required to provide all mandatory and most optional Medicaid benefits, but covered services may vary in amount, duration and scope. The waiver includes a provision for enhanced benefit accounts for beneficiaries practicing healthy lifestyle behaviors, with funds available to purchase additional services or to use toward employer-sponsored insurance premiums. If approved by CMS and the State legislature, the waiver could eventually be implemented statewide and include all Medicaid beneficiaries except the Medically Needy and those with retroactive eligibility. The tables reflect services available on a fee for service basis for the Medicaid population not yet included under the waiver.