Florida Healthy Kids

Medical and Prescription Benefits for Community Care Plan

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Value-Added Services

PCP Office Visit Copay Waiver

COVERAGE LIMITS: To ensure your child has all the needed care from his/her PCP, Community Care Plan.
- Florida Healthy Kids has waived the copays for any visit provided by the enrollee’s PCP. There is no limit to this benefit.

COPAY: $0

Sports/School Physical Copay Waiver

COVERAGE LIMITS: Community Care Plan – Florida Healthy Kids enrollees are eligible for an annual school or sports physical provided by the enrollee’s PCP with no copay. Limited to one (1) physical per enrollee per year.

COPAY: $0

Health Risk Assessment (HRA) Incentive

COVERAGE LIMITS: The Health Risk Assessment (HRA) helps Community Care Plan – Florida Healthy Kids better understand your child’s health needs. To encourage completion of the HRA, Community Care Plan.
– Florida Healthy Kids provides a onetime incentive of one (1) of the following:

  • A $25 gift card for completing the HRA within 30 calendar days of enrollment
  • A $20 gift card for completing the HRA within 60 calendar days of enrollment
  • A $15 gift card for completing the HRA within 90 calendar days of enrollment
COPAY: N/A

CVS ExtraCare Health Card

COVERAGE LIMITS: Community Care Plan – Florida Healthy Kids will provide one (1) CVS ExtraCare Health Card to each enrollee’s household by mail upon enrollment. The CVS ExtraCare Health Card provides a 20% discount on CVS brand over-the-counter health-related items available in CVS retail stores or online. One (1) CVS ExtraCare Health Card per household.

COPAY: N/A

Transportation for Medical and Dental Preventive Services

COVERAGE LIMITS: Must be approved by Community Care Plan – Florida Healthy Kids. Benefi t limited to $150 per episode of care. Reimbursement is only available when services are not available within the Community Care Plan – Florida Healthy Kids network. Enrollees must provide proof of relevant expenditures to receive reimbursement.

COPAY: $0

Hypoallergenic Bedding

COVERAGE LIMITS: Community Care Plan – Florida Healthy Kids provides up to $100 per year of hypoallergenic bedding for enrollees with an appropriate diagnosis of allergies or asthma for whom hypoallergenic bedding is medically necessary.

COPAY: $0

Provider House Calls

COVERAGE LIMITS: Community Care Plan – Florida Healthy Kids offers up to 20 visits per year for home visits by a licensed provider to enrollees who are homebound or who are not engaged with a PCP and need an emergency department follow-up visit. Must be approved by Community Care Plan – Florida Healthy Kids.

COPAY: $0

Healthy Behavior Coaching

COVERAGE LIMITS: Community Care Plan – Florida Healthy Kids offers individualized, in-person coaching programs for the following health behaviors:

  • Tobacco/nicotine cessation
  • Substance use disorder
  • Medically necessary supervised nutrition counseling for enrollees in need of weight management; program length is six (6) months

To support the enrollee and family, case management will be provided to track progress and remove barriers to success.

COPAY: $0

Obesity Program “Food, Fun, and Fit”

COVERAGE LIMITS: In partnership with other community organizations, Community Care Plan – Florida Healthy Kids offers a series of three (3) education workshops to address childhood obesity. You and your child will learn about healthy eating and adopting a healthier lifestyle. This program is tailored to each participating enrollee and will include a self-management assessment tool upon enrollment in the program, at three (3), six (6), and 12 months enrollment. As an incentive, each participating family receives a Bluetooth-enabled scale to help them and their PCP track the child’s progress.

  • All children ages 5-18 with a BMI at or above the 95th percentile for children and teens the same age and sex, as defined by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, are eligible for this program
  • Onetime benefit
COPAY: $0

Water Safety Classes “Swim, Seconds, and Safety”

COVERAGE LIMITS: In collaboration with local agencies, Community Care Plan – Florida Healthy Kids provides water safety and drowning prevention classes to all enrollees. You can request this benefi t for your child. Limited to one (1) set of classes per enrollee per lifetime.

COPAY: $0

Medical and Prescription Benefits

Well-Child Care (including preventive care visits, immunizations (shots), and routine hearing and vision screenings)

COVERAGE LIMITS: Hearing and vision screenings must be provided by your child’s PCP. You can get your immunizations from a Community Care Plan – Florida Healthy Kids network provider, pharmacy, minute clinic, or urgent care center

COPAY: $0

Primary Care Physician (PCP) Office Visits

COVERAGE LIMITS: Must use a Community Care Plan – Florida Healthy Kids network provider.

COPAY: $0; Community Care Plan has waived the copays for any visit provided by the member’s PCP

Specialist Office Visits

COVERAGE LIMITS: Must use a Community Care Plan – Florida Healthy Kids network provider.

COPAY: $5 per visit

Diagnostic Testing (laboratory, radiology, and other diagnostic tests)

COVERAGE LIMITS: Must use a Community Care Plan – Florida Healthy Kids network provider. Some diagnostic testing services may require approval from Community Care Plan – Florida Healthy Kids.

COPAY: $0

Prescription Drugs

COVERAGE LIMITS:

  • Must use a Community Care Plan – Florida Healthy Kids network pharmacy.
  • Generic drugs, unless the brand name is medically necessary.
  • Must be prescribed by your child’s PCP or a Community Care Plan – Florida Healthy Kids network specialist, doctor or Florida Healthy Kids dentist.
COPAY: $5 copay per prescription, up to a 31-day supply.

Inpatient Hospital Stays (semiprivate room)

COVERAGE LIMITS:

  • Must use a Community Care Plan – Florida Healthy Kids network hospital.
  • Stays must be approved by Community Care Plan – Florida Healthy Kids. Limited to 15 days per year for rehabilitation and physical therapy stays.
COPAY: $0 copay

Chiropractic services

COVERAGE LIMITS:

  • Limited to one visit per day for up to 24 visits per calendar year.
  • Must use a Community Care Plan – Florida Healthy Kids network provider
COPAY: $5 per visit

Podiatric Services Must be provided by a Community Care Plan – Florida Healthy Kids network provider.

COVERAGE LIMITS:

Limited to one visit per day for up to two visits per month for certain foot disorders.

COPAY: $5 per visit

Maternity services and newborn care, including prenatal and postpartum care, and the initial inpatient care of the newborn

COVERAGE LIMITS:

  • Must use a Community Care Plan – Florida Healthy Kids network provider.
  • Coverage for the newborn limited to three days after birth.
COPAY: $0 copay

Family Planning Services

COVERAGE LIMITS:

  • Must be provided by a Community Care Plan – Florida Healthy Kids network provider.
  • Limited to one (1) visit per year and one (1) supply visit every ninety (90) calendar days.
COPAY: $0 copay

Emergency services, including visits to an emergency room.

COVERAGE LIMITS:

If you have an emergency, call 911 or go to the nearest hospital emergency room right away.

  • You have the right to go to any hospital or provider if the time to reach a Community Care Plan – Florida Healthy Kids network provider would risk permanent damage to your child’s health.
  • If you want advice, call your PCP or our 24-hour Nurse Helpline at 1-833-925-0451.
COPAY: $10 per visit, waived if admitted or authorized by child’s PCP.

Emergency Transportation Services

COVERAGE LIMITS:

Transportation in response to an emergency medical condition.

COPAY: $10 per trip

Vision services, including an examination to determine the need for and to prescribe corrective lenses as medically necessary.

COVERAGE LIMITS:

  • Your child can receive one (1) new pair of glasses every two (2) years unless;
    • The prescription changes or
    • There is a change in the child’s head size.
COPAY: $5 per visit with specialist, $10 for corrective lenses

Behavioral Health Services, including inpatient and outpatient care for psychiatric evaluation, diagnosis, and treatment

COVERAGE LIMITS:

  • Emergency Room Services will be covered, no prior authorization or preapproval will be required.
  • Please call Carisk at 1-800-294-8642 for additional information on inpatient and outpatient behavioral health and substance abuse services.
COPAY: $0 copay for inpatient services, $5 per office visit

Substance Use Disorder Services, including inpatient and outpatient care for drug and alcohol abuse (such as counseling and help with placement assistance)

COVERAGE LIMITS:

  • Emergency Room Services will be covered, no prior authorization or preapproval will be required.
  • Please call Carisk at 1-800-294-8642 for additional information on inpatient and outpatient behavioral health and substance abuse services.
COPAY: $0 copay for inpatient services, $5 per office visit

Nursing facility services, including regular nursing services, rehabilitation services, semiprivate room Must be approved by Community Care Plan – Florida Healthy Kids and provided by a network facility.

COVERAGE LIMITS:

  • Limited to one hundred (100) days per year (rehabilitation and physical therapy stays are limited to fifteen (15) days per year)
  • Excludes private duty nurses, television, custodial care, specialized treatment centers, and independent kidney disease treatment centers.
COPAY: $0 copay

Short Term Therapy Services, including physical, occupational, respiratory and speech therapies for short-term rehabilitation when your child’s condition is expected to significantly improve

COVERAGE LIMITS:

  • Limited to twenty-four (24) sessions within a sixty (60) day Calendar Day period per incident. The sixty (60) Calendar Day period begins with the first treatment.
  • Please call Community Care Plan at 1-866-930-0944 to obtain provider and preapproval information.
  • Must be approved by Community Care Plan – Florida Healthy Kids.
COPAY: $5 per visit

Home Health Services, including prescribed home visits by registered and licensed practical nurses to provide skilled nursing services on a part-time intermittent basis

COVERAGE LIMITS:

  • Limited to skilled nursing services.
  • Meals, housekeeping and personal comfort items are excluded.
  • Private duty nursing is covered if medically necessary.
  • Please call Community Care Plan at 1-866-930-0944 to obtain provider and preapproval information.
COPAY: $5 per visit

Hospice services, including reasonable and necessary services to manage a terminal illness

COVERAGE LIMITS:

  • Must be approved by Community Care Plan – Florida Healthy Kids.
  • Covered services include prescribed home visits by registered or licensed practical nurses to provide skilled nursing services on a part-time intermittent basis.
  • Limited to skilled nursing services only. Meals, housekeeping and personal comfort items are excluded.
  • Private duty nursing is limited to circumstances where such care is medically necessary.
COPAY: $5 per visit, $0 for inpatient services

Durable medical equipment (DME) and prosthetic devices if prescribed by your child’s Community Care Plan-Florida Healthy Kids doctor as medically necessary.

  • Covered services include prescribed equipment and devices that are medically indicated to assist in the treatment of a medical condition.
  • Covered prosthetic devices include artificial eyes, limbs, braces, and other artificial aids.

COVERAGE LIMITS:

  • Some services may require approval by Community Care Plan – Florida Healthy Kids.
  • Low-vision and telescopic lenses are not included.
  • Hearing aids are covered only when medically indicated to assist in the treatment of a medical condition.
COPAY: $0 copay

Organ transplant services, including care before, during and after the transplant, and treatment of complications after the transplant

COVERAGE LIMITS:

  • Must be deemed medically necessary and appropriate within guidelines of AHCA’s Organ Transplant Advisory Council or the U.S Department of Health and Human Services’ the Bone Marrow Transplant Advisory Council.
  • Must be provided by a Community Care Plan – Florida Healthy Kids network provider and approved by Community Care Plan – Florida Healthy Kids.
COPAY: $0 copay