Medicaid

Medicaid is the state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid is different in every state. Eligibility for Medicaid is determined by the following agencies:

  • The Social Security Administration (SSA) determines eligibility for Supplemental Security Income (SSI);
  • The Florida Department of Children and Families (DCF) determines eligibility for low-­income children and families, aged persons, disabled persons, and persons seeking institutional care;
  • Florida Healthy Kids Corporation determines eligibility for MediKids.
  • The Agency for Health Care Administration (AHCA) is the single state agency responsible for Medicaid.

AHCA utilizes Provider Fee Schedules and Provider Handbooks to define the criteria and requirements for Medicaid services and providers. The Florida Medicaid Provider General Handbook, along with the service­specific “Coverage Policies” or “Coverage and Limitations and Reimbursement Handbooks” provide detailed information about Florida Medicaid services. Listed below are some of the most used policies/handbooks for individuals with Medicaid. Click here to see a complete list of Medicaid handbooks

Child Health Check

The Purpose of the Child Health Check–Up program is to provide the following services to children from birth through age 20:

  • Comprehensive, preventive, well child care on a regularly scheduled basis;
  • Identification and correction of medical conditions before the conditions become serious and disabling; and
  • An entry into the health care system.

Home Health

Home health services are medically necessary services, which can be safely provided in a recipient’s home or in the community. Services include home health visits (nurse and home health aide), private duty nursing and personal care services for children, therapy services, medical supplies, and durable medical equipment.

Therapy Services

The purpose of the therapy services program is to provide medically necessary physical therapy (PT), occupational therapy (OT), respiratory therapy (RT) and speech-­language pathology (SLP) services to recipients from birth through age 20.

The therapy services program also provides services to recipients age 21 and older for SLP services pertaining to the provision of augmentative and alternative communication systems, and PT and OT services pertaining to wheelchair evaluations and fittings. These are the only services in the therapy program that Medicaid reimburses for adults.

AHCA maintains a separate Coverage Policy for each therapy service.

PPEC

The purpose of the Florida Medicaid Prescribed Pediatric Extended Care (PPEC) Services Program is to enable children with medically­-complex conditions to receive medical and therapeutic care at a non­residential pediatric center. PPECs provide a cost effective and less restrictive alternative to private duty nursing (PDN) or institutionalization, and reduce the isolation that homebound children may experience. Private duty nursing may be provided as a wraparound alternative for an individual needing additional services, when PPEC is not available.

A PPEC is a non­residential facility that serves three or more children under the age of 21 who require short, long-­term, or intermittent medical care due to medically-­complex conditions. A PPEC offers services that meet the child’s physiological, developmental, nutritional, and social needs.

Statewide Medicaid Managed Care (SMMC) – Managed Medical Assistance (MMA)

The SMMC – MMA program is the delivery of Medicaid State Plan services through a Managed Care Plan that is contracted with AHCA. Florida transitioned most of its Medicaid recipients to the managed care delivery system in 2014. When recipients enroll in a Plan they are considered enrollees or members of that Plan and work with the Plan to access Medicaid services. The Plan must comply with all federal Medicaid regulations as well as AHCA’s Coverage Policies and Handbooks. Click here to see the plans available by region and frequently asked questions.

Statewide Medicaid Managed Care (SMMC) – Long Term Care (LTC) Waiver

The SMMC – LTC Waiver program is the delivery of Medicaid home and community based services through a Managed Care Plan that is contracted with AHCA. Once a Medicaid recipient is determined eligible for LTC services, they may enroll with a Plan that manages and coordinates the delivery of those services in the community through a person-centered Plan of Care. The Plan provides a Case Manager to coordinate those services. The Plan must comply with all federal Medicaid regulations as well as AHCA’s Coverage Policies and Handbooks. Click here to find the Plans available by region and frequently asked questions.

Developmental Disabilities Individual Budgeting Waiver (iBudget)

The iBudget Waiver program is the delivery of Medicaid home and community based services to individuals that meet the criteria of having a developmental or intellectual disability. Once a Medicaid recipient is determined eligible for the iBudget services, they select a Waiver Support Coordinator that manages and coordinates the delivery of those services in the community through a person-centered Support Plan. The ibudget is administered by the Agency for Persons with Disabilities and must comply with all federal Medicaid regulations as well as AHCA’s Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook. Click here to find more information about the iBudget Waiver.