In Florida:
  • As of July 1, 2011, there were 3,069,456 beneficiaries enrolled in the state’s Medicaid program, 1,958,679 of whom were enrolled in some form of managed care. 22 commercial managed care organizations (MCOs) and 6 Medicaid-only MCOs provide physical, behavioral, and oral health services to Medicaid beneficiaries.
  • For beneficiaries in counties not served by the comprehensive MCOs, the state also has four Prepaid Inpatient Health Plans (PIHPs) that provide medical benefits to 132,230 beneficiaries. Six mental health PIHPs provide services to 685,639 beneficiaries. Dental services are provided through two Prepaid Ambulatory Health Plans. Another PAHP in the state provides transportation benefits.
    • As of August 1, 2014, children with special health care needs receive physical behavioral, and oral health services from a statewide specialty health plan, Children’s Medical Services Network.
  • Children under age 21 who are medically complex/medically fragile are eligible for the state’s Medicaid Model Waiver, a home and community-based services waiver intended to prevent institutionalization.
As of 2013, 2,287,667 individuals were eligible for Florida’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known in the state as Child Health Check-up (part of the state’s Medicaid Children’s Medical Services). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 84% and a participant ratio of 57%. 604,239 children received dental services of any kind, with 497,141 receiving preventive dental services.
Last updated September 2014
Medical Necessity
The Florida Administrative Code (Rule 59G-1.010) states:
“ ‘Medically necessary’ or ‘medical necessity’ means that the medical or allied care, goods, or services furnished or ordered must:
  • Meet the following conditions:
    • Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;
    • Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;
    • Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
    • Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available; statewide; and
    • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.
  • “Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.
  • The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.”
Initiatives to Improve Access
Florida’s Children’s Medical Services (EPSDT) provider handbook requires that primary care providers have capacity to see and “render a clinical decision” on children 24 hours a day, 7 days a week.
The state allows physician extenders—Advanced Registered Nurse Practitioners and Physician Assistants—to provide services to Medicaid-enrolled children as long as the physician is responsible for managing the overall care of a child and concurs with the extender’s findings. Payment for these services is made to the supervising physician.
Reporting & Data Collection
Managed care organizations are required to report on a set of performance measures that include HEDIS measure for:
  • Adolescent Well Care Visits
  • Childhood Immunization Status
  • Follow-up for Children Prescribed ADHD Medication
  • Immunizations for Adolescents
  • Lead Screening in Children
  • Well-child Visits in the First 15 Months of Life
  • Well-child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
  • Children and Adolescents’ Access to Primary Care
The measure set also includes measures defined by the state Medicaid agency, including measures of transportation timeliness and availability.
Behavioral Health
Children enrolled in Florida’s Medicaid program have access to community-based behavioral health providers who can offer treatments such as Therapeutic Behavioral On-Site Services for Children and Adolescents, Behavioral Health Day Services for children under 5, and crisis intervention mental health services.
The state has made available (through managed care organizations) a Behavioral Health and Developmental Screening Form that can be used by providers to determine when a child should be referred for additional evaluation.
Medicaid-enrolled children on the autism spectrum can receive Applied Behavioral Analysis (ABA) services if they receive prior authorization. Providers must fill out an ABA review form.
Providers can also bill Medicaid for Screening, Brief Intervention and Referral to Treatment (SBIRT) services.
Support to Providers and Families
Support to Families
Florida’s Medicaid agency hosts a website informing families about services available to children as part of Child Health Check-up (the preventive services component of the EPSDT benefit). The state provides resources and guidance for families on how to choose a Medicaid managed care plan.
A set of Frequently of Asked Questions offers families additional information on the Medicaid managed care program. Recipient notices are used to communicate with Medicaid beneficiaries on changes to the program.
The state’s Medicaid agency also offers a “Florida Health Finder” tool that allows beneficiaries to compare: the quality of managed care plans, performance data on hospital and ambulatory surgery centers, and prices at Florida pharmacies. The tool also providers information on appropriate emergency room usage.

Support to Providers
Florida’s Medicaid agency operates a provider portal that offers information on the Medicaid program, including: policy bulletins, provider handbooks, Medicaid fee schedules, forms, and training opportunities on Medicaid policies and procedures. Providers also have the opportunity to log into a secure portion of the website to view data such as claims status and provider reports.
Care Coordination
Florida’s Medicaid program encourages pediatric primary care providers to serve as medical homes for children in need of care coordination services. Physicians delivering the EPSDT benefit receive support from nurses and social workers who help to coordinate care for enrolled families.
Services for Medicaid-enrolled children with special health care needs are managed the Children’s Medical Services Network, which partners with two integrated care systems:
  • A Pediatric Integrated Care System (“Ped-I-Care”) based at the University of Florida’s Department of Pediatrics, and
  • A South Florida Community Care Network comprised of the Broward Health and Memorial Healthcare Systems.
Oral Health
In Florida, DentaQuest administers the Children’s Medicaid Statewide Prepaid Dental Plan (a Prepaid Ambulatory Health Plan) and provides oral health services to Medicaid-enrolled children. The organization provides a statewide directory of participating dentists and offers a “find a dentist” tool to help families identify Medicaid-participating dentists.
A dental office reference manual offers providers guidance on covered oral health benefits and Medicaid procedures.