Medicaid Services

• The Florida Medicaid program is responsible for policies, procedures, and programs to promote access to quality acute and long-term medical, behavioral, therapeutic, and transportation services for Medicaid beneficiaries.  AHCA is also the lead agency for the Children’s Medical Insurance Programs (Title XXI –SCHIP).  As lead Medicaid Agency, AHCA also is responsible for the rules and federal compliance for waiver programs housed within other state agencies, such as the Developmentally Disabled Waiver and the Nursing Home Diversion Waiver.
  
  
• For additional information relating to Medicaid covered services please click on one of the tabs above.  A description of the services offered by the Florida Medicaid program can be found in our Summary of Services.
  
  
• Some Medicaid services are subject to utilization review by a Quality Improvement Organization (QIO) under contract with AHCA.
  
  
• During the rule making process, draft versions of handbooks, fee schedules and other documents related to fee for service and waiver rules are available to download.

Child Health Services

• Child Health Services
  Per Federal regulations, states are required to provide any medically necessary care required by child eligibles. 
  
  
• Florida KidCare
  Florida KidCare is the state's children health insurance program for uninsured children.
  
  
• MediKids
  MediKids is a Florida KidCare Program. Administered by the Agency for Health Care Administration, the program offers low-cost health insurance coverage for children ages 1 through 4.

Long-term Care

• Assistive Care Services
  Assistive Care Services is for low-income residents of enrolled assisted living facilities (ALFs), qualified residential treatment facilities (RTFs) and adult family-care homes (AFCHs).
  
  
• Home and Community Based Waivers
  Home and Community Based Waivers programs are the federally approved Medicaid programs authorized by Title XIX of the Social Security Act, Section 1915(c) that provide services in the home for persons who would otherwise require institutional care in a hospital, nursing facility, or intermediate care facility.
  
  
• Nursing Home Transition
  Nursing Home Transition is the voluntary transfer of an eligible Medicaid beneficiary residing in a nursing home to a community setting such as a family member’s home, an apartment or home, an Assisted Living Facility or Adult Family Care Home.
  
  
• Florida Long-term Care Partnership Program
  Florida’s Long-Term Care Partnership Program is a partnership program between Medicaid and private long-term care insurers designed to encourage individuals to purchase private long-term care insurance.
  
  
• Medicaid Nursing Facility Provider Information
  The Department of Children and Families (DCF) district offices staff determines eligibility for Institutional Care Program (ICP) services.
  
  
• Medicare Advantage Special Needs Plan (MA SNP)
  Florida Medicaid will coordinate with Medicaid enrolled Medicare Advantage Special Needs Plans to cover costs for beneficiaries who are eligible for both Medicare and Medicaid (duals), and who are enrolled in a Medicare Advantage Special Needs Plan (MA SNP).

Mental Health and Substance Abuse

• Medicaid Managed Behavioral Health Care
  Medicaid Managed Behavioral Health Care Advisory Forums are open public “fact-finding” or “information gathering” forums that are designed to promote the coordination, integration, quality, and efficiency of the mental health system of care.  This open public forum provides opportunities for beneficiaries, providers, and community stakeholders to discuss ideas and pose questions to the Managed Care Organizations and the Agency.
  
  
• Medicaid Certified Match Substance Abuse Program
  The Medicaid Certified Match Substance Abuse Program presents an opportunity for counties to increase local, public funds committed to substance abuse treatment for Medicaid recipients, by receiving federal matching funds for three new Medicaid funded substance abuse services. These three new Medicaid substance abuse services approved for the Local Medicaid Match Certification program are listed below:
  
  
  • Alcohol and/or Drug Intervention Services
  • Comprehensive Community Support Services
  • Comprehensive Community Support Services

Third Party Liability (TPL)

• Medicaid Third Party Liability (TPL)
  The Agency for Health Care Administration contracts with Xerox State Healthcare, LLC to conduct the Medicaid Third Party Liability (TPL) Program. Xerox is responsible for identifying additional sources of payments and recovering payments made by Medicaid from liable third parties.

Other Programs

• Medicaid Family Planning Waiver Program
  Medicaid Family Planning Waiver Program is a family planning program that is extended to women losing Medicaid eligibility within the past two years.  Eligible women may receive up to two years of extended family planning  services.
  
  
• Medical Equipment and Supplies (DME)
  DME is defined as medically-necessary equipment that can withstand repeated use, serves a medical purpose, and is appropriate for use in the recipient’s home as determined by the Agency for Health Care Administration (AHCA).
  
  
• Disease Management (Physician / Providers)
  Find out about our Disease Management programs and how they can help improve health outcomes for your patients.
  
  
• Disease Management (MediPass Members)
  Find out more about our Disease Management program for members with chronic diseases.

Statewide Medicaid Managed Care Program

• Statewide Medicaid Managed Care Program
  House Bill (HB) 7107, relating to Medicaid Managed Care, was passed by the Florida Legislature on May 6, 2011.  The bill outlines a comprehensive expansion of managed care for most Medicaid recipients throughout Florida.

Medicaid Reform Pilot

• Florida Medicaid Reform Technical Advisory Panel
  The Agency for Health Care Administration (AHCA) appointed nine people to serve on the Medicaid reform Technical Advisory Panel.  The Panel was created by the Florida Legislature in House Bill 3B and will advise AHCA on various implementation issues with Medicaid reform.
  
  
• Florida Medicaid Reform Pilot Main Page
  Florida is leading the nation in changing the Medicaid program. For the first time, we will offer true flexibility in the program so health plans can better target the needs of the program’s participants. We believe this innovative approach will better match health care services with the needs of the citizens we serve.
  
  
  • Medicaid Reform Waiver Extension
    
    
  • 1115 Amendment Request
    
    
  • Medicaid Reform Annual Reports
    
    
  • Medicaid Reform Quarterly Reports
    
    
  • Enhanced Benefits Reward$ Program
    • Recipients
    • Providers
      
      
  • Choice Counseling and Other Recipient Information
    
    
  • Provider Information
    
    
  • Low Income Pool (LIP)
    
    
  • Medicaid HMOs
    
    
  • Florida Medicaid Reform Implementation Plan
    
    
  • Florida Medicaid Reform - Approved 1115 Research and Demonstration Waiver Application
    
    
• Evaluation of Medicaid Reform 
  This contract is for the design and implementation of an independent Medicaid Reform Evaluation Study completed by the University of Florida, Department of Health Services Research, Management and Policy.  The goals of the evaluation are specifically intended to align with the goals of Medicaid Reform.

Statewide Prepaid Dental Program

• Statewide Prepaid Dental Health Plan
  In the 2010 proviso language (Specific Appropriation 204 of HB 5001), the Agency was directed to implement a statewide Prepaid Dental Health Plan (PDHP), with the exception of Miami-Dade where the existing pilot PDHP operates. Counties participating in the Reform Pilot are not included, resulting in the statewide PDHP program being implemented in 61 counties. Two vendors have been awarded contracts via an RFP process:  DentaQuest and Managed Care of North America (MCNA).
  
  
• Miami-Dade Prepaid Dental Program
  Proviso authorizes the Agency to maintain the Prepaid Dental Pilot program in Miami-Dade County. In July 2004, the state implemented the Prepaid Dental Health Plan program, limited to Medicaid eligible children 20 years of age or younger in Miami-Dade County, to expand the use of dental management organizations in order to improve access, contain cost, and eliminate fraud. The Agency is authorized to contract with up to three PDHP vendors in Miami-Dade county.  The Agency is currently contracting with two vendors to manage the program in Miami-Dade County; DentaQuest and Managed Care of North America (MCNA).

Managed Care Organizations

• Medicaid Managed Care Health Plan
  The Bureau of Managed Health Care is responsible for the monitoring of all Medicaid Managed Care Health Plan contracts in the state. Bureau staff conduct desk and on-site reviews throughout the year to ensure contract compliance.
  
  
• Provide Service Networks (PSN)
  PSN is a network established or organized and operated by a health care provider or group of affiliated health care providers, including minority physician networks and emergency room diversion programs that meet the requirements of Section 409.912 (4) (d) , F.S.
  
  
• Exclusive Provider Organization (EPO)
  EPOs are individual providers or groups of providers who have entered into written agreements with an insurer to provide health care services to subscribers.
  
  
• Prepaid Dental Health Plan
  Prepaid Dental Health Plans (PDHPs) are Medicaid managed dental care options available to Medicaid recipients in Miami-Dade County 20 years of age or younger who are not enrolledin an health maintenance organization (HMO) that provides dental services.
  
  
• Prepaid Mental Health Plan
  Prepaid Mental Health Plans (PMHPs) are comprehensive managed mental health care service plans that are available to a Medicaid recipients who are enrolled in MediPass, and Provider Service Networks for their physical health care services.  The Child Welfare PMHP is a specialized PMHP to address the complex needs of Medicaid-eligible children who are receiving specific services from the Department of Children and Families.  Child Welfare PMHP recipients may be enrolled in MediPass, HMOs, or Provider Service Networks for their physical health care services.
  
  
• Medicare Advantage Special Needs Program
  Florida Medicaid will coordinate with Medicaid enrolled Medicare Advantage Special Needs Program to cover costs for beneficiaries who are eligible for both Medicare and Medicaid (duals), and who are enrolled in a Medicare Advantage Special Needs Plan (MA SNP).
  
  
• Medicaid HMOs
  A Health Maintenance Organization (HMO) is an entity licensed under Chapter 641, Florida Statutes.   HMOs provide comprehensive Medicaid services to a defined population of Medicaid recipients.  HMOs are required by contract to ensure that their enrollees have access to all Medicaid state plan services and a complete network of providers.   HMO networks are not limited to Medicaid providers.  Some plans cover additional benefits beyond those paid for by Medicaid such as preventive adult dental.

MediPass Primary Care Case Management

• Medicaid Provider Access System (MediPass)
  MediPass is a primary care case management program for Medicaid beneficiaries developed and administered by Florida Medicaid. MediPass was established in 1991 to assure adequate access to coordinated primary care while decreasing the inappropriate utilization of medical services.
  
  
• Disease Management (Physician / Providers)
  Find out about our Disease Management programs and how they can help improve health outcomes for your patients.
  
  
• Disease Management (MediPass Members)
  Find out more about our Disease Management program for members with chronic diseases.
  

Managed Care Resources

• Managed Care Enrollment Reports
  This report shows Medicaid enrollment broken out in the following categories; a Comprehensive Report by Program and Assignment Plan, Medicaid Comprehensive Report By County, Medicaid Comprehensive Report By County and By Category of Eligibility , Market Share Report by Program and Plan, Medicaid Managed Care Plan [1915(b)] – HMO Enrollment by County, Medicaid Managed Care Plan [1915(b)] – HMO Enrollment by Category of Eligibility, Medicaid Managed Care Plan [1915(b)] – HMO TANF Enrollment by Age Group, Medicaid Managed Care Plan [1915(b)] – HMO SSI Enrollment by Age Group, Medicaid Pilot (1115) – Plan Enrollment by County, Medicaid Pilot (1115) – Plan Enrollment by Category of Eligibility, Medicaid Pilot (1115) – Provider TANF Enrollment by Age Group, Medicaid Pilot (1115) – Provider SSI Enrollment by Age Group.
  
  
• Florida Medicaid Quality in Managed Care
  Florida Medicaid is committed to ensuring that health care services delivered through managed care plans are held to high standards of quality and excellence. All vendors contracted with the Agency to provide managed care services must meet specific requirements for ensuring quality both in services provided and in administrative processes involved in oversight of the plan's operations.
  
  
• Medicaid Encounter Data System (MEDS) has been designed to collect, process, store, and report on managed care service activities and prescription drug utilization for all Florida Medicaid capitated health care providers and support specific information requests that may include: service utilization trends, quality of care, access to care, cost models, targeted studies, etc. MEDS will also support the risk model computations that set capitated payments for managed health care entities as defined in the Florida Medicaid Reform contracts.
  
  
• Choice Counseling and Other Beneficiary Information
  Medicaid has specially trained people to answer questions and help beneficiaries enroll in the health plan that best fits their needs. These people are called choice counselors and they provide services free of change. Beneficiaries can speak with a choice counselor by phone or meet with a choice counselor face-to-face.
  
  
• Enhanced Benefits Reward$ Program
  Florida Medicaid has a new program called the Enhanced Benefits Reward$ Program. This program is designed to reward recipients for taking part in activities that can improve your health. These activities, known as healthy behaviors, will earn credits that you can later use to buy health-related items at the pharmacy. You do not have to do anything to enroll in this program.
  
  
• Medicaid Options
  Medicaid Options is Florida's Medicaid managed care enrollment program for all counties except Baker, Broward, Clay, Duval and Nassau.  Qualified beneficiaries enroll through the toll-free Medicaid Options HelpLine to receive their health care services.

• Become a Florida Medicaid Health Plan
  Information, required documents for application submission and workshop information to become a Florida Medicaid Health Plan.

• Model Contracts and Amendments
  The consolidated model contracts can be found by clicking the above link.  The consolidated model contract is a streamlined version of the previous separate model health plan contracts (non-Reform, Reform, FFS PSN, capitated PSN, HMO and specialty plan for children with chronic conditions, and specialty plan for persons living with HIV/AIDS).  The Agency created one core contract that a health plan will sign with exhibits that detail any unique plan and population requirements of the particular plan (FFS PSN, capitated PSN, HMO, Reform or non-Reform, specialty population, age-group).
  

How to become a provider?

• Provider Enrollment
  Provider Enrollment is responsible for enrolling qualified providers to receive Medicaid reimbursement for services rendered to Medicaid recipients.
  
  
• Provider Enrollment Help Line Information
  Florida Medicaid's Web Portal solution provides communication and self-service tools to the provider community.

Already a Provider?

• Fiscal Agent
  Florida Medicaid currently has a contract with HP Enterprise Services (HP) to serve as the state's Fiscal Agent. Some of the fiscal agent functions include:
  • enroll non-institutional providers,
  • process Medicaid claims,
  • serve as the enrollment broker for Medicaid recipients, and
  • distribute Medicaid forms and publications.
    
    
• Public Information for Providers
  • Area Offices
  • Contact Us
  • Provider Support
    • Provider Bulletins
    • Provider Notices
    • Provider Handbooks
    • Provider Alerts
    • Fee Schedules
    • Forms
    • Recipient Notices
    • Training
    • FAQ
  • Provider Enrollment
    • Enrollment Status
    • Enrollment Wizart
    • Out-of-State Provider Enrollment
  • Electronic Data Interchange (EDI)
  • Managed Care
  • Pharmacy
  • Third Party Liability
  • National Provider Identifier
    
    
• Secure Information for Providers
  • Provider Demographic Maintenance
  • Prior Authorization Search
  • Recipient Eligibility
  • Claims Status
  • Claims Submission - Dental, Institutional, and Professional
  • Provider Reports
  • Trade Files Area
  • Third Party Liability
    
    

Florida Medicaid Electronic Health Record Incentive Program

• Florida Medicaid Electronic Health Record Incentive Program
  Florida Medicaid is implementing a federally approved program that will provide incentive payments to eligible professionals and eligible hospitals participating in Medicare and Medicaid programs to adopt, implement, or upgrade, and show meaningful use of Electronic Health Record (EHR) technology. 

Provider Resources

• Medicaid Fiscal Agent
  Florida Medicaid currently has a contract with HP Enterprise Services (HP) to serve as the state's fiscal agent. Some of the fiscal agent functions include: enroll non-institutional providers, process Medicaid claims, serve as the enrollment broker for Medicaid recipients, and distribute Medicaid forms and publications.
  
  
• HIPAA
  Information for the Health Insurance Portability and Accountability Act (HIPAA) can be found by clicking on the link above.
  
  
• Provider Fee Schedules
  The current Medicaid Provider Fee Schedules are to furnish the Medicaid provider with the appropriate fee schedules for covered services provided to eligible Florida Medicaid recipients.
  
  
• Provider Bulletins
  The Medicaid Provider Bulletins are published by the state Medicaid office and Florida Medicaid Fiscal Agent. The bulletins contain new policies, training opportunities, and other pertinent Medicaid information.
  
  
• Provider Handbooks
  The intent of the Medicaid Provider Handbooks is to furnish the Medicaid provider with policies and procedures needed to receive reimbursement for covered services provided to eligible Florida Medicaid recipients. The handbooks provide detailed descriptions and instructions on how and when to complete forms, letters, or other documentation.
  
  
• Preferred Drug List
  The Preferred Drug List (PDL) is a listing of cost effective therapeutic options recommended by the Medicaid Pharmacy and Therapeutics Committee.
  
  
• Enhanced Benefit$ Rewards Program
  The purpose of the Enhanced Benefit Account (EBA) program is to offer incentives to recipients enrolled in a Reform plan to participate in wellness activities also referred to as healthy behaviors.
  
  
• Medicaid Newborn Eligibility Policy
  Information regarding newborn eligibility and unborn activation procedures and related information.
  
  
• Medicaid Nursing Facility Provider Information
  The Department of Children and Families (DCF) district offices staff determines eligibility for Institutional Care Program (ICP) services.
  
  
• Florida Medicaid Provider Training e-Library
  Florida Medicaid Provider Training e-Library houses training resources for Medicaid providers.  You can go through the list of PowerPoint presentations and videos and select those that interest you to learn more about Florida Medicaid policy. 
  
  
• ICD-10
  Currently, health care entities are required by Federal regulations to use a standard code set to indicate diagnoses and procedures on transactions.  For diagnoses, the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code set is used.  For inpatient hospital procedures, the ICD-9 procedure code set (PCS) is used.  Effective October 1, 2014, the standard code set that is required for diagnosis codes is changing to the ICD-10-CM and the standard code set that is required for inpatient hospital procedures is changing to the ICD-10-PCS. 

Medicaid Cost Reimbursement

• Medicaid Institutional Provider Cost Reimbursement
  Medicaid Institutional Provider Cost Reimbursement is determined in the Medicaid Program Analysis Bureau. These providers include inpatient and outpatient hospital, nursing homes and ICF/DDs. This page contains links to some commonly requested documentation regarding the reimbursement of institutional providers.
  
  
• Reimbursement Workgroup Meetings
  
  

Florida Medicaid Provider Training e-Library

• Florida Medicaid Provider Training e-Library
  Welcome to the Florida Medicaid Provider Training e-Library that contains training resources for Medicaid providers on Medicaid policy.

Current Information

• Current Information
  
  
  • Current List of Drug Rebate Manufacturers
  • 100 Day Supply Maintenance Meds
  • Counterfeit-proof Prescription Blank Program
  • Dispensing Requirements for Dade, Broward, Monroe, and Palm Beach counties
  • Diverted Pharmaceuticals Program
  • Drug Efficacy Study Implementation (DESI) 5 Drug List
  • Medicaid Recipient Lock-in Program
  • Ombudsman Information and Request for Multi-Source Brand Drug Form
  • 5.1 Payer Specifications
  • D.O. Payer Specifications
  • Pharmacy Meeting Notices
  • Remittance Advice Provider Alerts
  • State MAC Pricing
  • MAC Pricing Request Form
  • Summary of Drug Limitations

Florida Medicaid Preferred Drug Program

• Preferred Drug List
  The Preferred Drug List (PDL) is a listing of cost effective therapeutic options recommended by the Medicaid Pharmacy and Therapeutics Committee.
  
  
• Prior Authorization Requirements and Forms
  In order to obtain copies of pharmacy prior authorization forms, please click on the following link above.
  
  
• Pharmaceutical and Therapeutics Committee
  The purpose of the Medicaid Pharmaceutical & Therapeutics Committee is to develop and implement a voluntary Medicaid preferred prescribed drug designation program, as mandated in the 2000 session of the Florida legislature, SB 2034.
  
  
• Provider Synergies
  Follow this link to access information regarding the Supplemental Rebate Process for Florida Medicaid.
  
  
• Drug Criteria
  Click on the above link to view drug criteria for Florida Medicaid. 

Drug Utilization and Prescribing Pattern Review

• Drug Utilization Review Board
  The Drug Utilization Board (DUR Board) reviews and approves drug use criteria and standards for both prospective and retrospective drug use reviews. It applies these criteria and standards in the application of DUR activities, reviews and reports the results of the drug use reviews, and recommends and evaluates the educational intervention programs.

• Medicaid Prescribing Pattern Review Panel
  The 1999 Florida Legislature mandated a Prescribing Pattern Review Panel to evaluate treatment guidelines and recommend ways to incorporate their use in the practice pattern identification program. Practitioners who are prescribing inappropriately or inefficiently, as determined by the agency, may have their prescribing of certain drugs subject to prior authorization.

Behavioral Health Medication Management Resources

• Behavioral Health Medication Management Resources

Pharmacy Reports and Presentations

• Report of Policy Review
  Oversight of Off-Label Prescribing of Atypical Antipsychotic Medications for Children Under Six Years of Age Covered by the Florida Medicaid Program.
  
  
• Medicaid Quarterly Spending Control Reports
  Medicaid Prescribed Drug Spending Control Program Initiatives.

General Information

• Sign Up for Health Care Alerts
  The Florida Medicaid program has an email alert system to supplement the present method of receiving Provider Alerts information and to notify registered providers or interested parties of "late-breaking" health care information.
  
  
• Summary of Services
  In Florida, the Agency for Health Care Administration (AHCA) develops and carries out policies related to the Medicaid program. A description of the services offered by the Florida Medicaid program can be found in the Summary of Services, 2011-2012.
  
  
• Medicaid Procurements
  Competitive solicitations (ITBs, RFPs, and ITNs), Requests for Information (RFIs) and other procurement documents issued by the Agency’s Procurement Office for the Division of Medicaid during Fiscal Years 2009-2010 and 2010-2011 are listed on this page. 
  
  
• Florida Medicaid State Plan
  Florida's Medicaid State Plan (the Plan) is a large, comprehensive written statement describing the scope and nature of the Medicaid program. The Plan outlines current Medicaid eligibility standards, policies and reimbursement methodologies to ensure the state program receives matching federal funds under Title XIX of the Social Security Act.

Reports and Presentations

• Recent Medicaid Presentations and Reports
  
  
• Reports of Medicaid Eligibles
  
  
• Eligibles Report  Archive
  
  
• Managed Care Enrollment Reports

Other Agency Resources

• Additional Medicaid Information
  • Brochure with Information on the Medicaid Program (Florida Health Finder.gov)
  • Brochure information relating to MediKids
  • Information relating to Medicaid Options
  • Information relating to Florida Medicaid Reform Choice Counseling
  • Provider Web Portal
    
    
• Additional Medicaid Eligibility Information
  • Information about applying for Medicaid (Department of Children and Families)
  • Submit a Medicaid application online (Department of Children and Families)
  • Information relating to KidCare (Florida KidCare)
  • Contact information for your Area’s Child Health Check-Up Coordinator
  • Supplemental Security Income (SSI) Programs Facts Sheet (Department of Children and Families) [311KB]
  • Family-Related Medicaid Programs Facts Sheet (Department of Children and Families)
    
    
• Other Agencies
  • Agency for Persons with Disabilities
  • Florida Department of Elder Affairs
  • Florida Department of Children and Families
  • Florida Department of Health
  • Florida Veterans Affairs
  • Medicare
  • Social Security Administration
    
    
• Alternative Medical Resources
  • Florida’s Health Safety Net Document [1.71MB]