This table lists the medical services that are covered by Sunshine Health. Remember, your child may need a referral from your child’s primary care provider (PCP) or approval from us before you go to an appointment or use a service. Services must be medically necessary (PDF) in order for us to pay for them.
There may be some services that we do not cover, but might still be covered by Medicaid. To find out about these benefits, call the Agency Medicaid Help Line at 1-877-254-1055. If you need a ride to any of these services, we can help you. You can call 1-877-659-8420 to schedule a ride.
If there are changes in covered services or other changes that will affect you, we will notify you in writing at least 30 days before the effective date of the change. If you have questions about any of the covered medical services, please call Member Services.
Except for emergency care, Sunshine Health must prior authorize any services to out-of-network providers and any elective inpatient admissions.
*Denotes services that are behavioral health in lieu of services. This means they are optional services you can choose over more traditional services based on your individual needs.
Services to treat conditions such as sneezing or rashes that are not caused by an illness.
We cover medically necessary blood or skin allergy testing and up to 156 doses per calendar year of allergy shots.
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.
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, for some procedures.
Services to keep you from feeling pain during surgery or other medical procedures.
Covered as medically necessary.
Yes, for dental procedures not done in an office.
Assistive Care Services
Services provided to adults (ages 18 and older) to help with activities of daily living and taking medication.
We cover 365/366 days of services per calendar year, as medically necessary.
Behavioral Health Assessment Services
Services used to detect or diagnose mental illnesses and behavioral health disorders.
We cover, as medically necessary:
Behavioral Health Overlay Services
Services provided in a group home setting for children ages 0 – 21 who have experienced trauma and are in the child welfare system.
We cover 365/366 days of services per calendar year, as medically necessary.
Services that treat the heart and circulatory (blood vessels) system.
We cover the following as prescribed by your doctor, when medically necessary:
Yes, for some services.
Child Health Services Targeted Case Management
Services provided to children ages 0-3 to help them get health care and other services.
Services provided to children (ages 0–20) who use medical foster care services.
Your child must be enrolled in the DOH Early Steps program.
Your child must be receiving medical foster care 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, as medically necessary:
Health care services provided in a county health department, federally qualified health center, or a rural health clinic.
Medically necessary services must be provided in a county health department, federally qualified health center or a rural health clinic.
Community- Based Wrap- Around Services*
Individualized care planning and care management service to support children with complex needs who are at risk of placement in a mental health treatment facility.
Children and youth up to age 21.
One per day with no limits per calendar year.
Crisis Stabilization Unit Services*
Emergency mental health services that are performed in a facility that is not a regular hospital.
One per day and no limit per calendar year.
No prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.
Detoxification or Addictions Receiving Facility Services*
Emergency substance abuse services that are performed in a facility that is not a regular hospital.
Up to a total of 15 days per month.
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, when medically necessary:
Drop-In Center Services*
A social club offering peer support and a flexible schedule of activities.
Covered as medically necessary.
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.
Yes, for some equipment or services.
Early Intervention Services
Services to children ages 0 - 3 who have developmental delays and other conditions.
We cover medically necessary:
Up to 2 training or support sessions per week
Emergency Transportation Services
Transportation provided by ambulances or air ambulances (helicopters or airplanes) to get you to a hospital because of an emergency.
Covered as medically necessary.
Evaluation and Management Services
Services for doctor’s visits to stay healthy and prevent or treat illness.
We cover medically necessary:
Family Therapy Services
Services for families to have therapy sessions with a mental health professional.
Up to 26 hours per calendar year, as medically necessary
Family Training and Counseling for Child Development*
Educational services for family members of children with severe emotional problems focused on child development and other family support.
Covered as medically necessary.
Services to treat conditions, illnesses, or diseases of the stomach or digestion system.
Covered as medically necessary.
Yes, for some services.
Services to treat conditions, illnesses, or diseases of the genitals or urinary system.
Covered as medically necessary.
Yes, for some services.
Group Therapy Services
Services for a group of people to have therapy sessions with a mental health professional.
We cover as medically necessary:
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, when medically necessary:
Yes, for some services.
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, when medically necessary:
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.
Individual Therapy Services
Services for people to have one-on-one therapy sessions with a mental health professional.
We cover, when medically necessary:
Infant Mental Health Pre and Post Testing Services*
Testing services by a mental health professional with special training in infants and young children.
Covered as medically necessary.
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, when medically necessary:
Services to diagnose or treat skin conditions, illnesses or diseases.
Covered as medically necessary.
Yes, for some services.
Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases.
Covered as medically necessary.
Yes, for some services.
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.
Medication Assisted Treatment Services
Services used to help people who are struggling with drug addiction.
Covered as medically necessary.
Medication Management Services
Services to help people understand and make the best choices for taking medication.
Covered as medically necessary.
Mental Health Targeted Case Management
Services to help get medical and behavioral health care for people with mental illnesses.
Covered as medically necessary.
Mobile Crisis Assessment and Intervention Services*
A team of health care professionals who provide emergency mental health services in the home, community, or school.
Covered as medically necessary.
Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system.
Covered as medically necessary.
Yes, for some services.
Non-Emergency Transportation Services
Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport people with disabilities, a taxi, or other kinds of vehicles.
We cover the following services for those who have no transportation:
Yes, for any trip over 100 miles.
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.
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 to 20 and for adults under the $1,500 outpatient services cap, as medically necessary:
We cover for people of all ages, as medically necessary:
Yes, for some services.
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, for some services.
Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.
Covered as medically necessary.
Yes, for some services.
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.
Yes, for some services.
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.
Partial Hospitalization Services*
Structured mental health treatment services provided in a hospital 4-6 hours each day for 5 days per week.
One per day and no limit per calendar year.
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 $1,500 outpatient services cap, as medically necessary:
We cover for people of all ages, as medically necessary:
Yes, for some services.
Medical care and other treatments for the feet.
We cover, as medically necessary:
Yes, for some services.
This service is for drugs that are prescribed to you by a doctor or other healthcare provider.
We cover, as medically necessary:
Yes, for some drugs.
Private Duty Nursing Services
Nursing services provided in the home to members 0-20 who need constant care.
Up to 24 hours per day, as medically necessary.
Psychological Testing Services
Tests used to detect or diagnose problems with memory, IQ or other areas.
10 hours of psychological testing per calendar year, as medically necessary.
Yes, for some services
Psychosocial Rehabilitation Services
Services to assist people to re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.
Up to 480 hours per calendar year, as medically necessary.
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, for some services
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.
Yes, for some 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 medically necessary 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.
Residential Outpatient Treatment
Short term residential treatment program for pregnant women with substance use disorder.
Ages 21 and older
Up to 60 days/calendar year
Services that treat conditions, illnesses or diseases of the lungs or respiratory system.
We cover medically necessary:
Yes, for some services.
Respiratory Therapy Services
Services for members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.
We cover medically necessary:
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.
Medical care or skilled nursing care that you get while you are in a nursing facility.
This can be a short- term or long-term rehabilitation stay.
Up to 60 days per calendar.
Specialized Therapeutic Services
Services provided to children ages
0-21 with mental illnesses or substance use disorders.
For children under the age of 21, we cover the following medically necessary services:
Speech- Language Pathology Services
Services that include tests and treatments to help you to talk or swallow better.
We cover the following medically necessary services for children ages 0 to 20:
We cover the following medically necessary services for adults:
Statewide Inpatient Psychiatric Program Services
Services for children with severe mental illnesses that need treatment in a secured facility.
Covered as medically necessary for ages 0 to 20.
Substance Abuse Intensive Outpatient Program*
Substance abuse treatment of detoxification services provided in an outpatient setting.
Covered as medically necessary.
Substance Abuse Short-term Residential Treatment Services/ Residential Outpatient Services*
Short-term substance abuse treatment in a residential program.
Covered as medically necessary. Maximum 60 days per calendar year.
Therapeutic Behavioral On- Site Services
Therapeutic services provided in the home or community to prevent children with mental illnesses from being placed in a hospital or other facility.
necessary for ages 0 to 20.
Up to 9 hours per month.
Services that include all surgery and pre- and post- surgical care.
Covered as medically necessary.
Visual Aid Services
Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes.
We cover the following medically necessary services when prescribed by your doctor:
- Two pairs of eyeglasses for children ages 0-20
Yes, for some services.
Visual Care Services
Services that test and treat conditions, illnesses and diseases of the eyes.
Covered as medically necessary.
Yes, for some services.