PHC Florida

Robert Heglar
AHF Provider

Covered Services

PHC Florida covers the following services.  Limitations and rules on how to get care are below.  This information is also in the Enrollee Handbook (effective December 1, 2018).  Look in Chapter 3.  If you have questions about covered services, please contact Member ServicesThe benefit information below is effective December 1, 2018.

Outpatient Hospital ServicesCovered when medically necessary; no limits; no co-pay; requires prior authorization

Medicaid Services Provided   Limitations
Advanced Registered Nurse Practitioner/Physician Assistant Services Covered when medically necessary; limited to one (1) visit per day; no co-pay; requires prior authorization
Ambulance Services For emergencies; covered when medically necessary; no limits; no co-pay
Ambulatory Surgery at an Ambulatory Surgery Center Covered when medically necessary; no limits; no co-pay; requires prior authorization
Behavioral Health Inpatient Hospital Services Covered; up to 45 days per year; no co-pay; requires prior authorization unless emergency.
Behavioral Health Outpatient Services Covered; no limits; no co-pay; certain services require prior authorization
Child Early Intervention Services Covered; no co-pay. Services for children ages 0-3 who have developmental delays and other conditions. Services include:

  • One initial evaluation per lifetime, completed by a team
  • Up to 3 screenings per year
  • Up to 3 follow-up evaluations per year
  • Up to 2 training or support sessions per week
Child Health Check-Up Services (CHCUP) Covered; no limits; no co-pay
Child Health Services Targeted Case Management Covered; no limits; no co-pay. Services provided to children (ages 0-3) to help them get health care and other services. Your child must be enrolled in the DOH Early Steps program.
Chiropractic Services Members may self-refer to a network chiropractor; covered when medically necessary; limited to one (1)   visit per day; limited to 24 visits per year; no co-pay; procedures require prior authorization
Clinical Services from Federally Qualified Health Care Centers Covered; limit of one (1) visit per day; no co-pay; certain services require prior authorization
Clinical Services from County Health Department Covered; limit of one (1) visit per day; no co-pay; certain services require prior authorization
Clinical Services from Rural Health Clinics Covered; limited to one (1) visit per day; no co-pay; certain services require prior authorization
Dental Services Routine dental services provided by a dentist are covered by your Medicaid dental plan. See your dental plan’s Enrollee Handbook for more information.

PHC Florida covers the following dental services:

  • Dental services provided by your PCP
  • Dental services rendered by a specialist (not a dentist) in a hospital or surgery center
  • Emergency dental services provided at a hospital
  • Prescription drugs for a dental visit or problem
  • Transportation to dental services and appointments
Dermatology Services Members may self-refer to a network dermatologist; covered when medically necessary; no co-pay;   procedures require prior authorization
Dialysis Services (hospital-based and free standing) Covered when medically necessary; no limits; no co-pay; requires prior authorization

Durable Medical Equipment and Medical Supplies
Covered when medically necessary; no co-pay; certain items and services require prior authorization.
Emergency Room Services Covered when medically necessary; no limits; no co-pay
Family Planning Services and Supplies including:

  • Education and Counseling
  • Initial Examination
  • Diagnostic Procedures and Lab Studies
  • Contraceptive Drugs/Supplies
Covered; no co-pay; certain services require prior authorization.

Hearing Services
Diagnostic testing, cochlear implants and hearing aids covered when medically necessary.  Diagnostic testing may be limited to once every three (3) years.  Hearing aids limited to once every three (3) years.  Newborn hearing screening covered.  No co-pay; certain services require prior authorization.
Healthy Start/Maternity Services including:

  • Prenatal Care and Screening
  • Obstetrical Delivery and Hospital Care
  • Birthing Center Services
  • Postnatal Risk Screening
  • Physician Care for Mother and Newborn
  • Nutrition Assessment and Counseling
Members may self-refer to a network OB/Gyn provider; covered when medically necessary; no co-pay; certain   services require prior authorization.  See Expanded Benefits for “Prenatal/Perinatal Services.”  The plan has enhanced prenatal/perinatal services to remove doctor visitation limits.
Home Health Care Services Covered when medically necessary; limited to four (4) intermittent visits per day; limited to 60 visits in a lifetime; no co-pay; requires prior authorization
Hospice Services Covered; enrollee must be certified by a physician as terminally ill with life expectancy of six (6) months or less; no co-pay.
Immunizations Covered; no limits; no co-pay
Inpatient Hospital Services Covered; up to 45 days per year; no co-pay; requires prior authorization unless emergency
Inpatient Hospital Substance Abuse Treatment Program Covered for pregnant substance abusers; up to 28 days per year; no co-pay; requires prior authorization.
Laboratory/X-Ray/Imaging Services Covered when medically necessary; no limits; no co-pay; certain services require prior authorization
Medical/Drug Therapies Covered when medically necessary; no limits; no co-pay; requires prior authorization
Medical Foster Care Services (services that help children with health problems who live in foster care homes) Covered; no limits; no co-pay. Must be in the custody of the Department of Children and Families.
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. Plan covers 365/366 days of services in nursing facilities as medically necessary. No co-pay; requires prior authorization.
Outpatient Surgery (Hospital) Covered when medically necessary; no limits; no co-pay; requires prior authorization
Optometric and Vision Services Exams, eyeglass frames, eyeglass lenses, repairs to eyeglasses covered.  Contact lenses covered if medically necessary.  Eyeglass frames limited to one (1) pair every two (2) years.  Eyeglass lenses limited to replacement once every year.  For members under the age of 21, eyeglass frames and lenses limited to replacement two (2) times a year.  No co-pay; additional services require prior authorization.  See Expanded Benefits for “Vision Services.”  Plan has an enhanced   eyeglass frame benefit.
Physician Primary Care Services See Expanded Benefits for “Physician Primary Care Services.”  Plan has enhanced this service to remove   doctor visit limits.
Physician Specialty Care Services Covered when medically necessary; limited to one (1) visit per day per specialist; no co-pay; referral and/or prior authorization required.
Podiatry Services Members may self-refer to network podiatrist; covered when medically necessary; limit of 24 visits per year; no co-pay; procedures require prior authorization
Prescription Drugs Covered when medically necessary; no limits; no co-pay; prior authorization required on certain drugs
Therapy Services (Hospital- and Community-Based) including:

  • Occupational Therapy
  • Physical Therapy
  • Respiratory Therapy
  • Speech Therapy
Covered when medically necessary; no limits; no co-pay; requires prior authorization.  No occupational or speech therapy coverage for adults.
Transplant Services Covered when medically necessary; no limits; no co-pay; requires prior authorization.  Intestinal/multivisceral transplant covered under Medicaid fee-for-service.
Transportation (Non-Emergency) Covered; no limits; no co-pay.  Plan must arrange transportation to and from plan-approved locations.
Tuberculosis Diagnosis and Treatment Services Covered; no limits; no co-pay.

 

The benefit information provided is a brief summary, not a complete description of benefits.  Limitations and restrictions apply.  Benefits, formulary, and/or pharmacy network may change.


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AHCA 110718 PHC MMA Form 17.1