Covered benefits CY19

Covered benefits CY19

The table below lists the medical services that are covered by Magellan Complete Care of Florida (MCC of FL). Remember, you may need a referral from your PCP or approval from us before you go to an appointment or use a service. If you have questions about any of the covered medical services, please call Customer Service.

There are no copayments for MCC of FL members.

Benefit Details
Service Details Coverage/Limitation Prior Authorization
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
Yes - for some procedures
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

No – emergency transportation

Yes – non-emergency transportation

Ambulatory Detoxification Services Services provided to people who are withdrawing from drugs or alcohol
  • Covered as medically necessary and recommended by us
Yes
 Ambulatory Surgical Center Services Surgery and other procedures that are performed in a facility that is not the hospital (outpatient)
  • Covered as medically necessary
Yes
Anesthesia Services Services to keep you from feeling pain during surgery or other medical procedures
  • Covered as medically necessary
Yes
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 – in-network providers
Behavioral Health Assessment Services Services used to detect or diagnose mental illnesses and behavioral health disorders
  • We cover unlimited
No
Behavioral Health Overlay Services Behavioral health services provided to children (ages 0 – 18) enrolled in a Department of Children and Families (DCF) program
  • Services in excess of the limits will be reviewed for medical necessity
Yes
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
Yes - for some procedures
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 unlimited services per expanded benefit
No
 Clinic Services Health care services provided in a county health department, federally qualified health center, or a rural health clinic
  • Visit to a federally qualified health center or rural health clinic visit
No
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
Yes
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 
We do not require a prior authorization at a network free standing facility
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 1-800-327-8613 (TTY 711) for more information

Yes - for some procedures

Items under $500 will not need PA if:

Provider is in-network. Item is not a rental

PA is not required regardless of item(s) price

Subject to coverage, exclusion, and limitations

Early Intervention Services Services to children ages 0 - 3 who have developmental delays and other conditions
  • We cover up to 2 training or support sessions per week
No
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
No
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
 
Family Therapy Services Services for families to have therapy sessions with a mental health professional
  • We cover unlimited services per expanded benefits
No
Gastrointestinal Services Services to treat conditions, illnesses, or diseases of the stomach or digestion system
  • We cover these services as medically necessary
Yes - for some procedures
Genitourinary Services Services to treat conditions, illnesses, or diseases of the genitals or urinary system
  • We cover these services as medically necessary
Yes - for some procedures
Group Therapy Services  Services for a group of people to have therapy sessions with a mental health professional
  • Unlimited services per expanded benefits
No
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 3 years
  • Repairs

No – evaluations

Yes – hearing aids

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
Yes
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
No
Individual Therapy Services Services for people to have one-to-one therapy sessions with a mental health professional
  • Unlimited services per expanded benefits
No – unless this exceeds 104 units per year
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)

No – emergency

Yes – elective behavioral and medical admissions

No – maternity/ newborn delivery

Yes – transplant

Yes – drug rehab for pregnant enrollees

Yes – electroconvulsive therapy (ECT)

Integumentary Services Services to diagnose or treat skin conditions, illnesses or diseases
  • Covered as medically necessary
Yes - for some procedures
Laboratory Services Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases
  • Covered as medically necessary
No
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 (DCF)
No
Medication Assisted Treatment Services  Services used to help people who are struggling with drug addiction
  • Covered as medically necessary
No
Medication Management Services Services to help people understand and make the best choices for taking medication
  • Covered as medically necessary
No
Mental Health Targeted Case Management Services to help get medical and behavioral health care for people with mental illnesses
  • Covered as medically necessary
Yes
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
Neurology Services Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system
  • Covered as medically necessary
Yes - for some procedures
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

Yes – trips greater than 50 miles. Trips three or more times a week to the same address. 10 or more trips in a month. Advanced life support, basic life support and bariatric wheelchairs. Out-of-area trips

Advanced scheduling required three business days prior to trip except for:

discharges, dialysis, cancer treatment, pre and post-surgery, surgery, wound care, and same-day mental health

Same-day pain management visits when the treating provider confirms the member cannot wait to be seen within the normal three business days’ notice

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 nursing facility services instead of inpatient hospital services.
  • Such services shall not be counted as inpatient hospital days and will require medical necessity review
Yes
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:

  • 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 late

Yes – requires medical necessary determination by the Plan

Subject to coverage, exclusion, and limitations

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
Yes
Orthopedic Services Services to diagnose or treat conditions, illnesses or diseases of the bones or joints
  • Covered as medically necessary
Yes - for some procedures
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
  • Unlimited with prior authorization
Yes
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
Yes
Partial Hospitalization Services Services for people leaving a hospital for mental health treatment
  • As medically necessary and recommended by us
Yes
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 outpatient services:

  • One initial evaluation per year
  • Up to 210 minutes of treatment per week
  • One initial wheelchair evaluation per 5 years

 

Yes – requires medical necessary determination by the Plan

Subject to coverage, exclusion, and limitations

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
Yes
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
No
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
Yes
Psychological Testing Services Tests used to detect or diagnose problems with memory, IQ or other areas
  • Unlimited
No
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
  • Unlimited with prior authorization and meeting medical necessity criteria
Yes
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
Yes – please go to RadMD.com to submit service requests
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
No
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.
Yes - for some procedures
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
Yes
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)
Yes
Self-Help/Peer Services Services to help people who are in recovery from an addiction or mental illness
  • As medically necessary and recommended by us
No
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
Yes
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
Yes
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
Yes
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 unlimited services with prior authorization and meeting medical necessity criteria
Yes
Transplant Services Services that include all surgery and pre and post-surgical care
  • Covered as medically necessary
Yes
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 -
One (1) pair of glasses every twelve (12) months

Yes -
Additional pairs of glasses

Visual Care Services Services that test and treat conditions, illnesses and diseases of the eyes
  • Covered as medically necessary

No – routine/preventive

Yes - ophthalmologist