What is Medicaid?
The Medicaid program provides medical care to low-income adults and their children, pregnant women, older adults, and people with disabilities. The Florida Agency for Health Care Administration (AHCA) is in charge of the making sure people get health care services with Florida Medicaid, and it is DCF’s job to sign you up for the Florida Medicaid program. Any child who is in the custody of DCF can get Medicaid benefits.
People who have Medicaid get their benefits through insurance plans. Many kids in foster care get their Medicaid benefits under the insurance plan called Sunshine Health, but there are other plans available.
What Medicaid insurance plan do I have?
You have the right to choose an insurance plan that meets your medical needs. Many children in foster care have the Medicaid plan called Sunshine Health. A list of Medicaid insurance plans may be found at AHCA’s website HERE.
Where can I find the rules and benefits of my insurance?
All Florida Medicaid insurance plans have a handbook that explains their policies, coverages, and benefits. For example, Sunshine Health provides a member handbook which explains their policies and outlines benefits. You can view this handbook HERE.
What are EPSDT benefits?
As a person who gets Medicaid, you have the right to get health care services to prevent and treat health conditions. This is called the EPSDT benefit, and you can get this until you turn 21 years old. The EPSDT benefit makes sure that children under the age of 21 get screenings, preventive services, and treatment services that are medically necessary. These services are under the following categories:
- Early: Looking for anything that could make you sick in the future.
- Periodic: Checking children’s health at certain ages.
- Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to look for problems.
- Diagnostic: Performing medical tests to find out what is making you sick.
- Treatment: Providing care for any health conditions you may have.
These services are included in your insurance plan.
What are medically necessary services?
Your Florida Medicaid insurance covers services that are necessary, or that you need, for your health. Medically necessary services are services that:
- You need to protect your life, to prevent sickness or disability, or to help pain.
- Treat problems and what is making you sick.
- Are allowed under the medical rules AHCA makes (cannot be experimental or investigational).
- Are the best option for you.
- Are given in a way that is helpful and not just the easiest option.
SCRAPPY TIP: Ask your doctor about what is medically necessary.
42 U.S.C. sec. 1396 Fla. Stat. sec. 409.903, 409.905, 409.964, 409.969, 409.967, Fla. Admin. Code R. 59G-1.010