Medicaid Benefits

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Standard benefits are offered by Medicaid. Expanded benefits are extra goods or services we provide to you, free of charge.

All

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Waived Copayments	All services including behavioral health	Ages 21+ years old	No Plan OK needed.	Adult		Expanded

Service	Waived Copayments
Description	All services including behavioral health
Coverage / Limitations	Ages 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Behavioral Health or Substance Use

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Addictions Receiving Facility Services	Services used to help people who are struggling with drug or alcohol addiction.	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All		Standard
Assessment/Evaluation Services – Behavioral	Evaluation and assessment for behavioral health. Call CCP Member Services.	One (1) every year. Must be 21+ years old	Plan OK needed.	Adult	$0	Expanded
Behavioral Health Assessment Services	Services used to detect or diagnose mental illnesses and behavioral health disorders.	We cover, as medically necessary: One initial assessment per year One reassessment per year Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)	No plan OK needed for initial 15 hours.	All		Standard
Behavioral Health Day Services/Day Treatment	Behavior Health Day Treatment	Maximum of 10 extra units per year of day treatment; one day per week up to 52 days per year of day care services. Must be 21+ years old	Plan OK needed.	Adult	$0	Expanded
Behavioral Health Medical Services (Drug Screening)	Alcohol or drug testing specimen. Call CCP Member Services.	Must be 21+ years old	No Plan OK needed.	Adult		Expanded
Behavioral Health Medical Services (Medication Management)	Help with special medications for substance use disorder. Call CCP Member Services.	Must be 21+ years old	No Plan OK needed.	Adult		Expanded
Behavioral Health Medical Services (Verbal Interaction)	Spoken communication for Mental Health/ Behavioral Health Medical Services, and Substance Abuse. Call CCP Member Services.	Must be 21+ years old	No Plan OK needed.	Adult		Expanded
Behavioral Health Overlay Services	Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program.	We cover 365/366 days of including therapy, support services and aftercare planning, per year, as medically necessary.	Plan OK needed for certain services.	All		Standard
Behavioral Health Screening Services	Behavioral Health Screening Services. Call CCP Member Services.	Must be 21+ years old	No Plan OK needed.	Adult		Expanded
Behavioral Health Services – Child Welfare	A special mental health program for children enrolled in a DCF program.	We cover as medically necessary and recommended by CCP.	Plan OK needed for certain services.	All		Standard
Computerized Cognitive Behavioral Therapy	Health Behavior assessment or re-assessment	Ages 21+ years old	Plan OK needed.	Adult		Expanded
Crisis Stabilization Unit Services	Emergency mental health services that are performed in a facility that is not a regular hospital.	We cover as medically necessary and recommended by CCP. 15 days per month	Plan OK needed.	All		Standard
Family Therapy Services	Services for families to have therapy sessions with a mental health professional.	We cover as medically necessary up to 26 hours per year.	No plan OK needed for up to 9 hours.	All		Standard
Family Training and Counseling for Child Development	Services to support a family during their child’s mental health treatment.	We cover as medically necessary and recommended by CCP.	No plan OK needed.	All		Standard
Group Therapy Services	Services for a group of people to have therapy sessions with a mental health professional.	We cover medically necessary up to 39 hours per year.	No plan OK needed for up to 9 hours.	All		Standard
Individual Therapy Services	Services for people to have one-to-one therapy sessions with a mental health professional.	We cover as medically necessary up to 26 hours per year.	No plan OK needed.	All		Standard
Individual Therapy Sessions for Caregivers	Visits with a behavioral health provider for caregivers of a member with Serious mental illness. Call CCP Member Services.	12 sessions per year. For caregivers of members ages six (6)years old.	Plan OK needed.	Serious Mental Illness	$0	Expanded
Infant Mental Health Pre and Post Testing Services	Testing services by a mental health professional with special training in infants and young children.	We cover as medically necessary and recommended by CCP.	No plan OK needed.	All		Standard
Intensive Outpatient Treatment – Behavioral	Outpatient for alcohol and/or drug treatment. Call CCP Member Services.	Unlimited if at an in-network facility. Ages 21+ years old	Plan OK needed.	Adult	$0	Expanded
Medication Assisted Treatment Services	Methadone administration for the treatment of substance use.	Must be given by a licensed program or provider. Ages 6+ years old	No Plan OK needed.	Serious Mental Illness		Expanded
Medication Assisted Treatment Services	Services used to help people who are struggling with drug addiction	We cover as medically necessary.	No plan OK needed.	All		Standard
Mental Health Partial Hospitalization Program Services	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from mental illness	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All		Standard
Mental Health Targeted Case Management	Services to help get medical and behavioral health care for people with mental illnesses	We cover as medically necessary.	No plan OK needed.	All		Standard
Mobile Crisis Assessment and Intervention Services	A team of health care professionals who provide emergency mental health services, usually in people’s homes	We cover as medically necessary and recommended by CCP.	No plan OK needed.	All		Standard
Multisystemic Therapy Services	An intensive service focused on the family for children at risk of residential mental health treatment	We cover as medically necessary and recommended by CCP.	No plan OK needed.	All		Standard
Peer Support Counseling	Group counseling sessions with people who have successfully managed behavioral health conditions. Call CCP Member Services.	12 sessions per year of individual or group sessions.	Plan OK needed.	Serious Mental Illness	$0	Expanded
Self-Help/Peer Services	Services to help people who are in recovery from an addiction or mental illness	We cover as medically necessary and recommended by CCP.	No plan OK needed.	All		Standard
Specialized Therapeutic Services	Services provided to children ages 0-20 with mental illnesses or substance use disorders.	We cover, as medically necessary: Assessments Foster care services Group home services	Plan OK needed.	Age 0 to 20		Standard
Statewide Inpatient Psychiatric Program Services	Services for children with severe mental illnesses that need treatment in the hospital.	As medically necessary for children ages 0-20.	Plan OK needed.	Age 0 to 20		Standard
Substance Abuse Intensive Outpatient Program Services	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders.	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All		Standard
Substance Abuse Treatment or Detoxification Services (Outpatient)	Treatment for substance use or detoxification in an outpatient setting	15 days per month.	Plan OK needed.	Adult		Expanded
Therapeutic Behavioral On-Site Services	Treatment programs to stabilize symptoms of behavioral health conditions. Call CCP Member Services.	Must be 21+ years old	Plan OK needed.	Adult	$0	Expanded
Therapy/ Psychotherapy (Individual/Family)	Individual or Family therapy for behavioral health issues. Call CCP Member Services.	Two (2) additional visits per year. Must be 21+ years old	Plan OK needed.	Adult	$0	Expanded
Therapy/Psychotherapy (Group)	Group therapy for behavioral health conditions	No limits. Must be 21+ years old.	No Plan OK needed.	Adult		Expanded

Service	Addictions Receiving Facility Services
Description	Services used to help people who are struggling with drug or alcohol addiction.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Assessment/Evaluation Services – Behavioral
Description	Evaluation and assessment for behavioral health. Call CCP Member Services.
Coverage / Limitations	One (1) every year. Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Behavioral Health Assessment Services
Description	Services used to detect or diagnose mental illnesses and behavioral health disorders.
Coverage / Limitations	We cover, as medically necessary: One initial assessment per year One reassessment per year Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)
Prior Authorization	No plan OK needed for initial 15 hours.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Behavioral Health Day Services/Day Treatment
Description	Behavior Health Day Treatment
Coverage / Limitations	Maximum of 10 extra units per year of day treatment; one day per week up to 52 days per year of day care services. Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Behavioral Health Medical Services (Drug Screening)
Description	Alcohol or drug testing specimen. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Behavioral Health Medical Services (Medication Management)
Description	Help with special medications for substance use disorder. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Behavioral Health Medical Services (Verbal Interaction)
Description	Spoken communication for Mental Health/ Behavioral Health Medical Services, and Substance Abuse. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Behavioral Health Overlay Services
Description	Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program.
Coverage / Limitations	We cover 365/366 days of including therapy, support services and aftercare planning, per year, as medically necessary.
Prior Authorization	Plan OK needed for certain services.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Behavioral Health Screening Services
Description	Behavioral Health Screening Services. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Behavioral Health Services – Child Welfare
Description	A special mental health program for children enrolled in a DCF program.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed for certain services.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Computerized Cognitive Behavioral Therapy
Description	Health Behavior assessment or re-assessment
Coverage / Limitations	Ages 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Crisis Stabilization Unit Services
Description	Emergency mental health services that are performed in a facility that is not a regular hospital.
Coverage / Limitations	We cover as medically necessary and recommended by CCP. 15 days per month
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Family Therapy Services
Description	Services for families to have therapy sessions with a mental health professional.
Coverage / Limitations	We cover as medically necessary up to 26 hours per year.
Prior Authorization	No plan OK needed for up to 9 hours.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Family Training and Counseling for Child Development
Description	Services to support a family during their child’s mental health treatment.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Group Therapy Services
Description	Services for a group of people to have therapy sessions with a mental health professional.
Coverage / Limitations	We cover medically necessary up to 39 hours per year.
Prior Authorization	No plan OK needed for up to 9 hours.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Individual Therapy Services
Description	Services for people to have one-to-one therapy sessions with a mental health professional.
Coverage / Limitations	We cover as medically necessary up to 26 hours per year.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Individual Therapy Sessions for Caregivers
Description	Visits with a behavioral health provider for caregivers of a member with Serious mental illness. Call CCP Member Services.
Coverage / Limitations	12 sessions per year. For caregivers of members ages six (6)years old.
Prior Authorization	Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay	$0
Benefit Type	Expanded

Service	Infant Mental Health Pre and Post Testing Services
Description	Testing services by a mental health professional with special training in infants and young children.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Intensive Outpatient Treatment – Behavioral
Description	Outpatient for alcohol and/or drug treatment. Call CCP Member Services.
Coverage / Limitations	Unlimited if at an in-network facility. Ages 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Medication Assisted Treatment Services
Description	Methadone administration for the treatment of substance use.
Coverage / Limitations	Must be given by a licensed program or provider. Ages 6+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay
Benefit Type	Expanded

Service	Medication Assisted Treatment Services
Description	Services used to help people who are struggling with drug addiction
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Mental Health Partial Hospitalization Program Services
Description	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from mental illness
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Mental Health Targeted Case Management
Description	Services to help get medical and behavioral health care for people with mental illnesses
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Mobile Crisis Assessment and Intervention Services
Description	A team of health care professionals who provide emergency mental health services, usually in people’s homes
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Multisystemic Therapy Services
Description	An intensive service focused on the family for children at risk of residential mental health treatment
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Peer Support Counseling
Description	Group counseling sessions with people who have successfully managed behavioral health conditions. Call CCP Member Services.
Coverage / Limitations	12 sessions per year of individual or group sessions.
Prior Authorization	Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay	$0
Benefit Type	Expanded

Service	Self-Help/Peer Services
Description	Services to help people who are in recovery from an addiction or mental illness
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Specialized Therapeutic Services
Description	Services provided to children ages 0-20 with mental illnesses or substance use disorders.
Coverage / Limitations	We cover, as medically necessary: Assessments Foster care services Group home services
Prior Authorization	Plan OK needed.
Age/Group	Age 0 to 20
Co-Pay
Benefit Type	Standard

Service	Statewide Inpatient Psychiatric Program Services
Description	Services for children with severe mental illnesses that need treatment in the hospital.
Coverage / Limitations	As medically necessary for children ages 0-20.
Prior Authorization	Plan OK needed.
Age/Group	Age 0 to 20
Co-Pay
Benefit Type	Standard

Service	Substance Abuse Intensive Outpatient Program Services
Description	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Substance Abuse Treatment or Detoxification Services (Outpatient)
Description	Treatment for substance use or detoxification in an outpatient setting
Coverage / Limitations	15 days per month.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Therapeutic Behavioral On-Site Services
Description	Treatment programs to stabilize symptoms of behavioral health conditions. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Therapy/ Psychotherapy (Individual/Family)
Description	Individual or Family therapy for behavioral health issues. Call CCP Member Services.
Coverage / Limitations	Two (2) additional visits per year. Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Therapy/Psychotherapy (Group)
Description	Group therapy for behavioral health conditions
Coverage / Limitations	No limits. Must be 21+ years old.
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Behavioral Health or Substance Use, Medical

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Psychological Testing Services	Tests used to detect or diagnose problems with memory, IQ, or other areas.	We cover, as medically necessary, 10 hours of psychological testing per year.	No Plan OK needed.	All		Standard

Service	Psychological Testing Services
Description	Tests used to detect or diagnose problems with memory, IQ, or other areas.
Coverage / Limitations	We cover, as medically necessary, 10 hours of psychological testing per year.
Prior Authorization	No Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Education

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Financial Literacy	Life coaching for money management & budgeting. Teens can also learn about saving money. Financial investment guidance, financial counseling, financial consultation, advice, tax consultation and a 25% discount on tax preparation and credit repair. Get started today.	Community Care Plan knows that money can impact your health. We want to help. We have teamed up with KOFE: Knowledge of Financial Education to help improve the financial health of our members. You now have access to resources and tools about things like money, spending, credit, credit cards, and more. You can also call the toll-free number to talk to a financial coach. You have all the tools you need to reach your financial goals!	No Plan OK needed.	Age 13+	$0	Expanded
Tutoring K-12	On-demand 24/7 tutoring services. Tutor.com is open 24 hours a day, seven days a week. With Tutor.com, you can connect with a tutor live and get personal help with homework, writing, and studying for tests for: 100+ subjects (math, science, English, writing, history, and more). All grades, kindergarten to 12th! Get started today.	2 hours per week	No Plan OK needed.	Age 5 to 19	$0	Expanded
Tutoring, Vocational Training & Job Readiness	On-demand 24/7 tutoring for GED preparation. Get started today. Tutor.com is open 24 hours a day, seven days a week. Get started today.	2 hours per week Must not have a High School diploma or GED certificate Ages 18+ years old	Plan OK needed.	Adult	$0	Expanded

Service

Description

Coverage/Limitations

Prior Authorization

Age/Group

Co-Pay

Benefit Type

Financial Literacy

Life coaching for money management & budgeting. Teens can also learn about saving money. Financial investment guidance, financial counseling, financial consultation, advice, tax consultation and a 25% discount on tax preparation and credit repair.
Get started today.

Community Care Plan knows that money can impact your health. We want to help. We have teamed up with KOFE: Knowledge of Financial Education to help improve the financial health of our members. You now have access to resources and tools about things like money, spending, credit, credit cards, and more. You can also call the toll-free number to talk to a financial coach. You have all the tools you need to reach your financial goals!

No Plan OK needed.

Age 13+

Expanded

Tutoring K-12

On-demand 24/7 tutoring services.

Tutor.com is open 24 hours a day, seven days a week. With Tutor.com, you can connect with a tutor live and get personal help with homework, writing, and studying for tests for:
100+ subjects (math, science, English, writing, history, and more).

All grades, kindergarten to 12th!
Get started today.

2 hours per week

No Plan OK needed.

Age 5 to 19

Expanded

Tutoring, Vocational Training & Job Readiness

On-demand 24/7 tutoring for GED preparation. Get started today.

Tutor.com is open 24 hours a day, seven days a week.

Get started today.

2 hours per week
Must not have a High School diploma or GED certificate

Ages 18+ years old

Plan OK needed.

Adult

Expanded

Service	Financial Literacy
Description	Life coaching for money management & budgeting. Teens can also learn about saving money. Financial investment guidance, financial counseling, financial consultation, advice, tax consultation and a 25% discount on tax preparation and credit repair. Get started today.
Coverage / Limitations	Community Care Plan knows that money can impact your health. We want to help. We have teamed up with KOFE: Knowledge of Financial Education to help improve the financial health of our members. You now have access to resources and tools about things like money, spending, credit, credit cards, and more. You can also call the toll-free number to talk to a financial coach. You have all the tools you need to reach your financial goals!
Prior Authorization	No Plan OK needed.
Age/Group	Age 13+
Co-Pay	$0
Benefit Type	Expanded

Service	Tutoring K-12
Description	On-demand 24/7 tutoring services. Tutor.com is open 24 hours a day, seven days a week. With Tutor.com, you can connect with a tutor live and get personal help with homework, writing, and studying for tests for: 100+ subjects (math, science, English, writing, history, and more). All grades, kindergarten to 12th! Get started today.
Coverage / Limitations	2 hours per week
Prior Authorization	No Plan OK needed.
Age/Group	Age 5 to 19
Co-Pay	$0
Benefit Type	Expanded

Service	Tutoring, Vocational Training & Job Readiness
Description	On-demand 24/7 tutoring for GED preparation. Get started today. Tutor.com is open 24 hours a day, seven days a week. Get started today.
Coverage / Limitations	2 hours per week Must not have a High School diploma or GED certificate Ages 18+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Equipment & Supplies

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Breast Pump	Device used by lactating mothers to pump breast milk	One Breast Pump every four (4) years	No Plan OK needed.	Pregnant	$0	Expanded
Breast Pump-Hospital Grade	An electronic pump used by hospitals for lactating mothers to pump breast milk	One Breast Pump (Rental Only) every year	Plan OK needed.	Pregnant		Expanded
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.	We cover as medically necessary. Some service and age limits apply. Call 1-866-899-4828 for more information.	Plan OK needed for some Durable Medical Equipment and Medical Supplies Services.	All		Standard
Glucose Monitoring	Device that measures blood sugar	No limits with OK	Plan OK needed.	Adult		Expanded
Hospital Bed	Durable Medical Equipment	One (1) Hospital Bed every five (5) years	Plan OK needed.	Adult		Expanded

Service	Breast Pump
Description	Device used by lactating mothers to pump breast milk
Coverage / Limitations	One Breast Pump every four (4) years
Prior Authorization	No Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Breast Pump-Hospital Grade
Description	An electronic pump used by hospitals for lactating mothers to pump breast milk
Coverage / Limitations	One Breast Pump (Rental Only) every year
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay
Benefit Type	Expanded

Service	Durable Medical Equipment and Medical Supplies Services
Description	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.
Coverage / Limitations	We cover as medically necessary. Some service and age limits apply. Call 1-866-899-4828 for more information.
Prior Authorization	Plan OK needed for some Durable Medical Equipment and Medical Supplies Services.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Glucose Monitoring
Description	Device that measures blood sugar
Coverage / Limitations	No limits with OK
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Hospital Bed
Description	Durable Medical Equipment
Coverage / Limitations	One (1) Hospital Bed every five (5) years
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Home Health and Community Based Services

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Caregiver Support	Training and Educational Support for Caregivers of members living with serious mental illness. Call CCP Member Services.	No limits for caregivers of members over six (6)years old.	Plan OK needed.	Serious Mental Illness	$0	Expanded
Community-Based Wrap-Around Services	Services provided by a mental health team to children who are at risk of going into a mental health treatment facility.	We cover as medically necessary.	Plan OK needed.	All	$0	Standard
Drop-In Center Services	Services provided in a center that helps homeless people get treatment or housing.	We cover as medically necessary.	No plan OK needed.	All		Standard
Food Assistance	Meals delivered to your home. Call CCP Member Services.	28 meals per year. Ages 18+ years old.	Plan OK needed.	Adult	$0	Expanded
Healthy Meal Delivery After Birth	Meals delivered to your home after you have a baby. Call CCP Member Services or your Care Coordinator.	2 meals per day for up to 28 days.	Plan OK needed.	Pregnant	$0	Expanded
Home Delivered Meals – Disaster Preparedness/ Relief	Home delivered meals before or after a natural disaster. Call CCP Member Services.	One (1) per year	Plan OK needed.	Adult	$0	Expanded
Home Delivered Meals – Post-Facility Discharge (Hospital or Nursing Facility)	Home delivered meals after going home from a hospital or nursing home stay. Call CCP Member Services.	Ten (10) meals one (1) time per year. Must be 21+ years old.	Plan OK needed.	Adult	$0	Expanded
Home Delivered Meals (Pregnant)	Meals delivered to your home when you are pregnant. Call CCP Member Services or your Care Coordinator.	2 meals per day for up to 28 days.	Plan OK needed.	Minor - under 18	$0	Expanded
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: Up to 4 visits per day for pregnant recipients and recipients ages 0-20 Up to 3 visits per day for all other recipients	Plan OK needed.	All		Standard
Home Visit by a Clinical Social Worker	Services of a clinical social worker in home health or hospice setting. Call CCP Member Services.	48 visits per year	Plan OK needed.	Adult	$0	Expanded
Legal Guardianship*	To help pay legal fees for services such as a power of attorney when their mental health condition makes the member unable to make decisions for themselves. Call CCP Member Services.	$500 per lifetime Ages 6+ years old	Plan OK needed.	Serious Mental Illness	$0	Expanded
Medically Related Home Care Services*/Homemaker	Carpet cleaning. Call CCP Member Services or your Care Coordinator.	Two (2) times per year. The member must have a diagnosis of asthma. Ages 21+ years old.	Plan OK needed.	Adult	$0	Expanded
Private Duty Nursing Services	Nursing services provided in the home to people ages 0 to 20 who need constant care.	We cover up to 24 hours per day, as medically necessary.	Plan OK needed.	Age 0 to 20		Standard

Service	Caregiver Support
Description	Training and Educational Support for Caregivers of members living with serious mental illness. Call CCP Member Services.
Coverage / Limitations	No limits for caregivers of members over six (6)years old.
Prior Authorization	Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay	$0
Benefit Type	Expanded

Service	Community-Based Wrap-Around Services
Description	Services provided by a mental health team to children who are at risk of going into a mental health treatment facility.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay	$0
Benefit Type	Standard

Service	Drop-In Center Services
Description	Services provided in a center that helps homeless people get treatment or housing.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Food Assistance
Description	Meals delivered to your home. Call CCP Member Services.
Coverage / Limitations	28 meals per year. Ages 18+ years old.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Healthy Meal Delivery After Birth
Description	Meals delivered to your home after you have a baby. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	2 meals per day for up to 28 days.
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Home Delivered Meals – Disaster Preparedness/ Relief
Description	Home delivered meals before or after a natural disaster. Call CCP Member Services.
Coverage / Limitations	One (1) per year
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Home Delivered Meals – Post-Facility Discharge (Hospital or Nursing Facility)
Description	Home delivered meals after going home from a hospital or nursing home stay. Call CCP Member Services.
Coverage / Limitations	Ten (10) meals one (1) time per year. Must be 21+ years old.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Home Delivered Meals (Pregnant)
Description	Meals delivered to your home when you are pregnant. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	2 meals per day for up to 28 days.
Prior Authorization	Plan OK needed.
Age/Group	Minor - under 18
Co-Pay	$0
Benefit Type	Expanded

Service	Home Health Services
Description	Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness, or injury.
Coverage / Limitations	We cover when medically necessary: Up to 4 visits per day for pregnant recipients and recipients ages 0-20 Up to 3 visits per day for all other recipients
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Home Visit by a Clinical Social Worker
Description	Services of a clinical social worker in home health or hospice setting. Call CCP Member Services.
Coverage / Limitations	48 visits per year
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Legal Guardianship*
Description	To help pay legal fees for services such as a power of attorney when their mental health condition makes the member unable to make decisions for themselves. Call CCP Member Services.
Coverage / Limitations	$500 per lifetime Ages 6+ years old
Prior Authorization	Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay	$0
Benefit Type	Expanded

Service	Medically Related Home Care Services*/Homemaker
Description	Carpet cleaning. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	Two (2) times per year. The member must have a diagnosis of asthma. Ages 21+ years old.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Private Duty Nursing Services
Description	Nursing services provided in the home to people ages 0 to 20 who need constant care.
Coverage / Limitations	We cover up to 24 hours per day, as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	Age 0 to 20
Co-Pay
Benefit Type	Standard

Hospital

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Benefit Type
Partial Hospitalization Services	Services for people leaving a hospital for mental health treatment	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All	Standard
Psychiatric Specialty Hospital Services	Emergency mental health services that are performed in a facility that is not a regular hospital.	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All	Standard
Specialty Psychiatric Hospitals	In lieu of Inpatient Psychiatric Hospital	We cover as medically necessary and recommended by CCP.	No plan OK needed.		Standard

Service	Partial Hospitalization Services
Description	Services for people leaving a hospital for mental health treatment
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Psychiatric Specialty Hospital Services
Description	Emergency mental health services that are performed in a facility that is not a regular hospital.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Specialty Psychiatric Hospitals
Description	In lieu of Inpatient Psychiatric Hospital
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	No plan OK needed.
Age/Group
Co-Pay
Benefit Type	Standard

Maternity

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
24/7 Access to Virtual Lactation & Pregnancy Support	Mobile app with 24/7 access to a live doula or lactation counselor. Call CCP Member Services or your Care Coordinator.	Must be pregnant or have had a baby in the past twelve (12) months.	Plan OK needed.	Pregnant	$0	Expanded
Maternal OUD/SUD Peer Support	Support from someone who has overcome opioid or substance use. Call CCP Member Services or your Care Coordinator.	Limited to pregnant women.	Plan OK needed.	Pregnant	$0	Expanded
Maternity New Mom Package	Portable Crib & Monitor. Call CCP Member Services or your Care Coordinator.	Must take a safe sleep class. Limited to pregnant women	Plan OK needed.	Pregnant	$0	Expanded
Member Support including Companionship	Companionship visits and support. Visit www.CCPcares.org/Papa to learn more.	60 hours per rolling 12 months For Pregnant women and new moms up to 12 months after your baby is born.	Plan OK needed.	Pregnant	$0	Expanded
Member Support including Companionship	Companionship visits and support. Visit www.CCPcares.org/Papa to learn more.	60 hours per rolling 12 months. For any member ages 13+ years old.	Plan OK needed.	Serious Mental Illness	$0	Expanded
Phone Application for Pregnant Women	Access to remote case management via cell phone application. Call your Care Coordinator.	For high-risk pregnancies only	Plan OK needed.	Pregnant	$0	Expanded
Social Media Safety Classes	Free classes for kids and parents to keep yourself safe online. Call CCP Member Services.	Must be 14+ years old	Plan OK needed.	Age 14+	$0	Expanded

Service	24/7 Access to Virtual Lactation & Pregnancy Support
Description	Mobile app with 24/7 access to a live doula or lactation counselor. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	Must be pregnant or have had a baby in the past twelve (12) months.
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Maternal OUD/SUD Peer Support
Description	Support from someone who has overcome opioid or substance use. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	Limited to pregnant women.
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Maternity New Mom Package
Description	Portable Crib & Monitor. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	Must take a safe sleep class. Limited to pregnant women
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Member Support including Companionship
Description	Companionship visits and support. Visit www.CCPcares.org/Papa to learn more.
Coverage / Limitations	60 hours per rolling 12 months For Pregnant women and new moms up to 12 months after your baby is born.
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Member Support including Companionship
Description	Companionship visits and support. Visit www.CCPcares.org/Papa to learn more.
Coverage / Limitations	60 hours per rolling 12 months. For any member ages 13+ years old.
Prior Authorization	Plan OK needed.
Age/Group	Serious Mental Illness
Co-Pay	$0
Benefit Type	Expanded

Service	Phone Application for Pregnant Women
Description	Access to remote case management via cell phone application. Call your Care Coordinator.
Coverage / Limitations	For high-risk pregnancies only
Prior Authorization	Plan OK needed.
Age/Group	Pregnant
Co-Pay	$0
Benefit Type	Expanded

Service	Social Media Safety Classes
Description	Free classes for kids and parents to keep yourself safe online. Call CCP Member Services.
Coverage / Limitations	Must be 14+ years old
Prior Authorization	Plan OK needed.
Age/Group	Age 14+
Co-Pay	$0
Benefit Type	Expanded

Medical

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Additional PCP Visits for Adults	Visits to your primary care doctor for any reason.	No limits.	No Plan OK needed.	Adult		Expanded
Allergy Services	Services to treat conditions such as sneezing or rashes that are not caused by an illness.	We cover as medically necessary: Blood or skin allergy testing Up to 156 doses per year of allergy shots	Plan OK needed.	All		Standard
Ambulatory Surgical Center Services	Surgery and other procedures that are performed in a facility that is not the hospital (outpatient).	We cover as medically necessary.	Plan OK needed.	All		Standard
Anesthesia Services	Services to keep you from feeling pain during surgery or other medical procedures	We cover as medically necessary.	Plan OK needed.	All		Standard
Cardiovascular Services	Services that treat the heart and circulatory (blood vessels) system.	We cover the following as prescribed by your doctor, when medically necessary: Cardiac testing Cardiac surgical procedures Cardiac devices	Plan OK needed for certain invasive services.	All		Standard
Child Health Services Targeted Case Management	Services provided to children (ages 0 – 3) to help them get health care and other services OR Services provided to children (ages 0 – 20) who use medical foster care services.	Your child must be enrolled in the DOH Early Steps program Or your child must be receiving medical foster care services.	No plan OK needed.	Ages 0 to 20		Standard
Clinic Services	Health care services provided in a county health department, federally qualified health center, or a rural health clinic.	We cover as medically necessary.	No plan OK needed.	All		Standard
Dialysis Services	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 as prescribed by your treating doctor, as medically necessary: Hemodialysis treatments Peritoneal dialysis treatments	Plan OK needed.	All		Standard
Doula Services	Doulas are a non-medical person who supports pregnant women, before, during and after pregnancy. Call CCP Member Services or your Care Coordinator.	Unlimited for Pregnant women	No Plan OK needed.	Pregnant		Expanded
Early Intervention Services	Services to children ages 0 – 3 who have developmental delays and other conditions.	We cover as medically necessary: 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	No plan OK needed.	Age 0 to 3		Standard
Evaluation and Management Services	Services for doctor’s visits to stay healthy and prevent or treat illness.	We cover as medically necessary: One adult health screening (check-up) per year Well child visits are provided based on age and developmental needs One visit per month for people living in nursing facilities Up to two office visits per month for adults to treat illnesses or conditions	No plan OK needed.	All		Standard
Gastrointestinal Services	Services to treat conditions, illnesses, or diseases of the stomach or digestion system.	We cover as medically necessary.	Plan OK needed for invasive procedures.	All		Standard
Genitourinary Services	Services to treat conditions, illnesses, or diseases of the genitals or urinary system.	We cover as medically necessary.	Plan OK needed for invasive procedures.	All		Standard
Hospice Services	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	We cover as medically necessary.	Plan OK needed.	All		Standard
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 these inpatient hospital services based on age and situation, asmedically necessary: Up to 365/366 days for recipients ages 0-20 Up to 45 days for all other recipients (extra days are covered for emergencies)	Plan OK needed.	All		Standard
Integumentary Services	Services to diagnose or treat skin conditions, illnesses, or diseases.	We cover as medically necessary.	Plan OK needed for invasive procedures.	All		Standard
Laboratory Services	Services that test blood, urine, saliva, or other items from the body for conditions, illnesses, or diseases.	We cover as medically necessary.	Plan OK needed for genetic testing.	All		Standard
Neurology Services	Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord, or nervous system.	We cover as medically necessary.	Plan OK needed for some procedures.	All		Standard
Newborn Circumcision	Circumcision for male infants at the initial hospitalization visit, in the physician’s office, or participating outpatient facility.	One per lifetime within the first 12 weeks after birth.	No Plan OK needed.	Age 0 - 12 weeks		Expanded
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	We cover 365/366 days of services in nursing facilities as medically necessary.	No plan OK needed.	All		Standard
Nutritional Counseling	Provides you with information on the right type of foods to eat based on your health needs. Call CCP Member Services.	Unlimited with in-network provider. Ages 21+ years old	Plan OK needed.	Adult	$0	Expanded
Oral Surgery Services	Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity.	We cover as medically necessary.	Plan OK needed for some procedures.	All		Standard
Orthopedic Services	Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.	We cover as medically necessary.	Plan OK needed for Invasive procedures and advanced imaging services (such as MRI or CAT scan).	All		Standard
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.	We cover as medically necessary: Emergency services Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over	Plan OK needed for some invasive procedures and overnight hospital observation.	Adult		Standard
Pain Management Services	Treatments for long-lasting pain that does not get better after other services have been provided	We cover as medically necessary.	Plan OK needed for some invasive procedures.	All		Standard
Podiatry Services	Medical care and other treatments for the feet	We cover as medically necessary: Up to 24 office visits per year Foot and nail care X-rays and other imaging for the foot, ankle, and lower leg Surgery on the foot, ankle, or lower leg	Plan OK needed for invasive surgery.	All		Standard
Prenatal Services	Visits to ensure that you and your baby are healthy during and after your pregnancy	14 visits for low-risk pregnancies 18 visits for high-risk pregnancies	No Plan OK needed	Pregnant		Expanded
Radiology and Nuclear Medicine Services	Services that include imaging such as x-rays, MRIs, or CAT scans. They also include portable x-rays.	We cover as medically necessary.	Plan OK needed for advanced imaging such as MRI or CAT scans. No Plan OK needed for x-rays.	All		Standard
Regional Perinatal Intensive Care Center Services	Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions.	We cover as medically necessary.	No Plan OK needed.	All		Standard
Reproductive 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 family planning services, as medically necessary. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. These services are free. These services are voluntary and confidential, even if you are under 18 years old.	No plan OK needed.	Age 14+		Standard
Respiratory Services	Services that treat conditions, illnesses or diseases of the lungs or respiratory system.	We cover as medically necessary: Respiratory testing Respiratory surgical procedures Respiratory device management	Plan OK needed for some invasive procedures and devices.	All		Standard
Respiratory Therapy for Adults	Respiratory therapy includes treatments to help you breathe easier when being treated for a respiratory illness or condition. Call CCP Member Services.	One (1) per year, visits after evaluation will vary based on need. Must be 21+ years old	Plan OK needed.	Adult		Expanded
Targeted Case Management	Targeted Case Management. Call CCP Member Services.	Must be 21+ years old	Plan OK needed.	Adult	$0	Expanded
Transplant Services	Services that include all surgery and pre- and post-surgical care.	We cover as medically necessary.	Plan OK needed.	All		Standard

Service	Additional PCP Visits for Adults
Description	Visits to your primary care doctor for any reason.
Coverage / Limitations	No limits.
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Allergy Services
Description	Services to treat conditions such as sneezing or rashes that are not caused by an illness.
Coverage / Limitations	We cover as medically necessary: Blood or skin allergy testing Up to 156 doses per year of allergy shots
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Ambulatory Surgical Center Services
Description	Surgery and other procedures that are performed in a facility that is not the hospital (outpatient).
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Anesthesia Services
Description	Services to keep you from feeling pain during surgery or other medical procedures
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Cardiovascular Services
Description	Services that treat the heart and circulatory (blood vessels) system.
Coverage / Limitations	We cover the following as prescribed by your doctor, when medically necessary: Cardiac testing Cardiac surgical procedures Cardiac devices
Prior Authorization	Plan OK needed for certain invasive services.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Child Health Services Targeted Case Management
Description	Services provided to children (ages 0 – 3) to help them get health care and other services OR Services provided to children (ages 0 – 20) who use medical foster care services.
Coverage / Limitations	Your child must be enrolled in the DOH Early Steps program Or your child must be receiving medical foster care services.
Prior Authorization	No plan OK needed.
Age/Group	Ages 0 to 20
Co-Pay
Benefit Type	Standard

Service	Clinic Services
Description	Health care services provided in a county health department, federally qualified health center, or a rural health clinic.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Dialysis Services
Description	Medical care, tests, and other treatments for the kidneys. This service also includes dialysis supplies, and other supplies that help treat the kidneys.
Coverage / Limitations	We cover as prescribed by your treating doctor, as medically necessary: Hemodialysis treatments Peritoneal dialysis treatments
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Doula Services
Description	Doulas are a non-medical person who supports pregnant women, before, during and after pregnancy. Call CCP Member Services or your Care Coordinator.
Coverage / Limitations	Unlimited for Pregnant women
Prior Authorization	No Plan OK needed.
Age/Group	Pregnant
Co-Pay
Benefit Type	Expanded

Service	Early Intervention Services
Description	Services to children ages 0 – 3 who have developmental delays and other conditions.
Coverage / Limitations	We cover as medically necessary: 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
Prior Authorization	No plan OK needed.
Age/Group	Age 0 to 3
Co-Pay
Benefit Type	Standard

Service	Evaluation and Management Services
Description	Services for doctor’s visits to stay healthy and prevent or treat illness.
Coverage / Limitations	We cover as medically necessary: One adult health screening (check-up) per year Well child visits are provided based on age and developmental needs One visit per month for people living in nursing facilities Up to two office visits per month for adults to treat illnesses or conditions
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Gastrointestinal Services
Description	Services to treat conditions, illnesses, or diseases of the stomach or digestion system.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for invasive procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Genitourinary Services
Description	Services to treat conditions, illnesses, or diseases of the genitals or urinary system.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for invasive procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Hospice Services
Description	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
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Inpatient Hospital Services
Description	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.
Coverage / Limitations	We cover these inpatient hospital services based on age and situation, asmedically necessary: Up to 365/366 days for recipients ages 0-20 Up to 45 days for all other recipients (extra days are covered for emergencies)
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Integumentary Services
Description	Services to diagnose or treat skin conditions, illnesses, or diseases.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for invasive procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Laboratory Services
Description	Services that test blood, urine, saliva, or other items from the body for conditions, illnesses, or diseases.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for genetic testing.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Neurology Services
Description	Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord, or nervous system.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for some procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Newborn Circumcision
Description	Circumcision for male infants at the initial hospitalization visit, in the physician’s office, or participating outpatient facility.
Coverage / Limitations	One per lifetime within the first 12 weeks after birth.
Prior Authorization	No Plan OK needed.
Age/Group	Age 0 - 12 weeks
Co-Pay
Benefit Type	Expanded

Service	Nursing Facility Services
Description	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
Coverage / Limitations	We cover 365/366 days of services in nursing facilities as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Nutritional Counseling
Description	Provides you with information on the right type of foods to eat based on your health needs. Call CCP Member Services.
Coverage / Limitations	Unlimited with in-network provider. Ages 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Oral Surgery Services
Description	Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for some procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Orthopedic Services
Description	Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for Invasive procedures and advanced imaging services (such as MRI or CAT scan).
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Outpatient Hospital Services
Description	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.
Coverage / Limitations	We cover as medically necessary: Emergency services Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over
Prior Authorization	Plan OK needed for some invasive procedures and overnight hospital observation.
Age/Group	Adult
Co-Pay
Benefit Type	Standard

Service	Pain Management Services
Description	Treatments for long-lasting pain that does not get better after other services have been provided
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for some invasive procedures.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Podiatry Services
Description	Medical care and other treatments for the feet
Coverage / Limitations	We cover as medically necessary: Up to 24 office visits per year Foot and nail care X-rays and other imaging for the foot, ankle, and lower leg Surgery on the foot, ankle, or lower leg
Prior Authorization	Plan OK needed for invasive surgery.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Prenatal Services
Description	Visits to ensure that you and your baby are healthy during and after your pregnancy
Coverage / Limitations	14 visits for low-risk pregnancies 18 visits for high-risk pregnancies
Prior Authorization	No Plan OK needed
Age/Group	Pregnant
Co-Pay
Benefit Type	Expanded

Service	Radiology and Nuclear Medicine Services
Description	Services that include imaging such as x-rays, MRIs, or CAT scans. They also include portable x-rays.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed for advanced imaging such as MRI or CAT scans. No Plan OK needed for x-rays.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Regional Perinatal Intensive Care Center Services
Description	Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Reproductive Services
Description	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.
Coverage / Limitations	We cover family planning services, as medically necessary. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. These services are free. These services are voluntary and confidential, even if you are under 18 years old.
Prior Authorization	No plan OK needed.
Age/Group	Age 14+
Co-Pay
Benefit Type	Standard

Service	Respiratory Services
Description	Services that treat conditions, illnesses or diseases of the lungs or respiratory system.
Coverage / Limitations	We cover as medically necessary: Respiratory testing Respiratory surgical procedures Respiratory device management
Prior Authorization	Plan OK needed for some invasive procedures and devices.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Respiratory Therapy for Adults
Description	Respiratory therapy includes treatments to help you breathe easier when being treated for a respiratory illness or condition. Call CCP Member Services.
Coverage / Limitations	One (1) per year, visits after evaluation will vary based on need. Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Targeted Case Management
Description	Targeted Case Management. Call CCP Member Services.
Coverage / Limitations	Must be 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Transplant Services
Description	Services that include all surgery and pre- and post-surgical care.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Medication

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Medication Management Services	Services to help people understand and make the best choices for taking medication	We cover as medically necessary.	No plan OK needed.	All		Standard
Prescribed Drug Services	This service is for drugs that are prescribed to you by a doctor or other health care provider	We cover as medically necessary: Up to a 34-day supply of drugs, per prescription Refills, as prescribed	Plan OK needed for some medications. No copay for covered medications.	All		Standard

Service	Medication Management Services
Description	Services to help people understand and make the best choices for taking medication
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Prescribed Drug Services
Description	This service is for drugs that are prescribed to you by a doctor or other health care provider
Coverage / Limitations	We cover as medically necessary: Up to a 34-day supply of drugs, per prescription Refills, as prescribed
Prior Authorization	Plan OK needed for some medications. No copay for covered medications.
Age/Group	All
Co-Pay
Benefit Type	Standard

Other

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Acupuncture	Acupuncture	Must be 21 + years old.	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.	Adult		Expanded
Adult Hearing Aid Services	Assessment for a Hearing Aid	One (1) every 2 years. Must be 21+ years old.	No Plan OK needed.	Adult		Expanded
Assistive Care Services	Services provided to adults (ages 18 and older) help with activities of daily living and taking medication.	We cover 365/366 days of services per year, as medically necessary.	No plan OK needed when services are rendered in an Assisted Living Facility, Adult family care home, or Residential treatment facility.	All		Standard
Cellular Phone Services	Free cell phone with minutes and texting. Call CCP Member Services.	Ages 21+ years old	Plan OK needed.	Adult	$0	Expanded
Chiropractic Services	Chiropractor visits	Thirteen (13) extra chiropractic visits per year. Ages 21+ years old	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.	Adult		Expanded
Chiropractic 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: 24 patient visits per year, per member X-rays	Plan OK needed after 24 visits per year, up to a maximum of 37 visits.	All		Standard
Fitness Membership*	Gym or fitness allowance. Call CCP Member Services.	Ages 18+ years old	Plan OK needed.	Adult	$0	Expanded
Hearing Services	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: Cochlear implants One new hearing aid per ear, once every 3 years Repairs	Plan OK needed for cochlear implants.	All		Standard
Housing Assistance*	Help paying for housing related needs. Call CCP Member Services.	$250 once per lifetime. Must be 18+ years old.	Plan OK needed.	Adult	$0	Expanded
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.	No plan OK needed.	All		Standard
Over The Counter Benefit	Over the counter medicines and medical supplies to improve health. Order online anytime at athome.medline.com/ccpfl. Call 833-660-0908 (TTY:711) OTC Benefit Service reps can help you Monday–Friday, 8 am–8 pm EST. Fill out the order form in the back of the catalog. Mail it to the address on the form. It may take up to 4 weeks to process mailed orders. Have your member ID ready when you order.	$50 per household per month.	No Plan OK needed.	All	$0	Expanded
Swimming Lessons (Drowning Prevention)*	Swimming lessons for kids. Call CCP Member Services.	Covered up to $200 per year. This is limited to 1,000 members per year. Ages 3 to 18 years old.	Plan OK needed.	Age 3 to 18	$0	Expanded

Service	Acupuncture
Description	Acupuncture
Coverage / Limitations	Must be 21 + years old.
Prior Authorization	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Adult Hearing Aid Services
Description	Assessment for a Hearing Aid
Coverage / Limitations	One (1) every 2 years. Must be 21+ years old.
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Assistive Care Services
Description	Services provided to adults (ages 18 and older) help with activities of daily living and taking medication.
Coverage / Limitations	We cover 365/366 days of services per year, as medically necessary.
Prior Authorization	No plan OK needed when services are rendered in an Assisted Living Facility, Adult family care home, or Residential treatment facility.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Cellular Phone Services
Description	Free cell phone with minutes and texting. Call CCP Member Services.
Coverage / Limitations	Ages 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Chiropractic Services
Description	Chiropractor visits
Coverage / Limitations	Thirteen (13) extra chiropractic visits per year. Ages 21+ years old
Prior Authorization	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Chiropractic Services
Description	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.
Coverage / Limitations	We cover, as medically necessary: 24 patient visits per year, per member X-rays
Prior Authorization	Plan OK needed after 24 visits per year, up to a maximum of 37 visits.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Fitness Membership*
Description	Gym or fitness allowance. Call CCP Member Services.
Coverage / Limitations	Ages 18+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Hearing Services
Description	Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.
Coverage / Limitations	We cover hearing tests and the following as prescribed by your doctor, when medically necessary: Cochlear implants One new hearing aid per ear, once every 3 years Repairs
Prior Authorization	Plan OK needed for cochlear implants.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Housing Assistance*
Description	Help paying for housing related needs. Call CCP Member Services.
Coverage / Limitations	$250 once per lifetime. Must be 18+ years old.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Medical Foster Care Services
Description	Services that help children with health problems who live in foster care homes.
Coverage / Limitations	Must be in the custody of the Department of Children and Families.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Over The Counter Benefit
Description	Over the counter medicines and medical supplies to improve health. Order online anytime at athome.medline.com/ccpfl. Call 833-660-0908 (TTY:711) OTC Benefit Service reps can help you Monday–Friday, 8 am–8 pm EST. Fill out the order form in the back of the catalog. Mail it to the address on the form. It may take up to 4 weeks to process mailed orders. Have your member ID ready when you order.
Coverage / Limitations	$50 per household per month.
Prior Authorization	No Plan OK needed.
Age/Group	All
Co-Pay	$0
Benefit Type	Expanded

Service	Swimming Lessons (Drowning Prevention)*
Description	Swimming lessons for kids. Call CCP Member Services.
Coverage / Limitations	Covered up to $200 per year. This is limited to 1,000 members per year. Ages 3 to 18 years old.
Prior Authorization	Plan OK needed.
Age/Group	Age 3 to 18
Co-Pay	$0
Benefit Type	Expanded

Therapy

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
Massage Therapy	Therapeutic massage	Two (2) hours per month. Must be 21 + years old.	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.	Adult	$0	Expanded
Occupational Therapy Evaluation for Adults	Evaluation for occupational therapy treatments	One per year. Ages 21+ years old	No Plan OK needed.	Adult		Expanded
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	For children ages 0 – 20 and for adults under the $1,500 outpatient services cap, we cover as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years For people of all ages, we cover, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later	Plan OK needed.	Age 0 to 20		Standard
Physical Therapy for Adults	Evaluation for physical therapy treatments	One evaluation per year. Must be 21+ years old	No Plan OK needed	Adult		Expanded
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	For children ages 0 – 20 and for adults under the $1,500 outpatient services cap, we cover, as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years For people of all ages, we cover, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later	Plan OK needed except for initial evaluation and re-evaluations.	All		Standard
Psychosocial Rehabilitation	Psychosocial rehabilitation treatments	Unlimited with OK	Plan OK needed.	Adult		Expanded
Psychosocial Rehabilitation Services	Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.	We cover up to 480 hours per year, as medically necessary.	No Plan OK needed for up to 240 hours.	All		Standard
Respiratory Therapy Services	Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness, or disease. We cover as medically necessary: – One initial evaluation per year – One therapy re-evaluation per 6 months – Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)		Plan OK needed except for initial evaluation and re-evaluations.	Age 0 to 20	$0	Standard
Speech Therapy for Adults	Speech therapy includes treatments to help you talk or swallow better. Call CCP Member Services.	One (1) per year. Visits after evaluation will vary based on need.	Plan OK needed.	Adult	$0	Expanded
Speech-Language Pathology Services	Services that include tests and treatments help you talk or swallow better.	For children ages 0-20, we cover, as medically necessary: Communication devices and services Up to 210 minutes of treatment per week One initial evaluation per year For adults, we cover, as medically necessary: One communication evaluation per 5 years	Plan OK needed except for initial evaluation and re-evaluations	All		Standard
Therapy – Art	Uses music, dance, or art therapies, not for recreation, to treat behavioral health conditions.	Ages 7-21 years old	Plan OK needed.	Age 7 to 21		Expanded
Therapy – Equine	Uses horses to treat a variety of conditions	Ten (10) sessions. Ages 7-21 years old	Plan OK needed.	Age 7 to 21		Expanded
Therapy – Pet	Uses animals to help people recover from or cope with health problems or mental disorders.	Must be 7+ years old	Plan OK needed.	Age 7+		Expanded

Service	Massage Therapy
Description	Therapeutic massage
Coverage / Limitations	Two (2) hours per month. Must be 21 + years old.
Prior Authorization	Plan OK needed. Must get a referral from a plan Pain Specialist or Cancer doctor.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Occupational Therapy Evaluation for Adults
Description	Evaluation for occupational therapy treatments
Coverage / Limitations	One per year. Ages 21+ years old
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Occupational Therapy Services
Description	Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house
Coverage / Limitations	For children ages 0 – 20 and for adults under the $1,500 outpatient services cap, we cover as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years For people of all ages, we cover, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later
Prior Authorization	Plan OK needed.
Age/Group	Age 0 to 20
Co-Pay
Benefit Type	Standard

Service	Physical Therapy for Adults
Description	Evaluation for physical therapy treatments
Coverage / Limitations	One evaluation per year. Must be 21+ years old
Prior Authorization	No Plan OK needed
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Physical Therapy Services
Description	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
Coverage / Limitations	For children ages 0 – 20 and for adults under the $1,500 outpatient services cap, we cover, as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years For people of all ages, we cover, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later
Prior Authorization	Plan OK needed except for initial evaluation and re-evaluations.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Psychosocial Rehabilitation
Description	Psychosocial rehabilitation treatments
Coverage / Limitations	Unlimited with OK
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Psychosocial Rehabilitation Services
Description	Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.
Coverage / Limitations	We cover up to 480 hours per year, as medically necessary.
Prior Authorization	No Plan OK needed for up to 240 hours.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Respiratory Therapy Services
Description	Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness, or disease. We cover as medically necessary: – One initial evaluation per year – One therapy re-evaluation per 6 months – Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)
Coverage / Limitations
Prior Authorization	Plan OK needed except for initial evaluation and re-evaluations.
Age/Group	Age 0 to 20
Co-Pay	$0
Benefit Type	Standard

Service	Speech Therapy for Adults
Description	Speech therapy includes treatments to help you talk or swallow better. Call CCP Member Services.
Coverage / Limitations	One (1) per year. Visits after evaluation will vary based on need.
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Speech-Language Pathology Services
Description	Services that include tests and treatments help you talk or swallow better.
Coverage / Limitations	For children ages 0-20, we cover, as medically necessary: Communication devices and services Up to 210 minutes of treatment per week One initial evaluation per year For adults, we cover, as medically necessary: One communication evaluation per 5 years
Prior Authorization	Plan OK needed except for initial evaluation and re-evaluations
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Therapy – Art
Description	Uses music, dance, or art therapies, not for recreation, to treat behavioral health conditions.
Coverage / Limitations	Ages 7-21 years old
Prior Authorization	Plan OK needed.
Age/Group	Age 7 to 21
Co-Pay
Benefit Type	Expanded

Service	Therapy – Equine
Description	Uses horses to treat a variety of conditions
Coverage / Limitations	Ten (10) sessions. Ages 7-21 years old
Prior Authorization	Plan OK needed.
Age/Group	Age 7 to 21
Co-Pay
Benefit Type	Expanded

Service	Therapy – Pet
Description	Uses animals to help people recover from or cope with health problems or mental disorders.
Coverage / Limitations	Must be 7+ years old
Prior Authorization	Plan OK needed.
Age/Group	Age 7+
Co-Pay
Benefit Type	Expanded

Transportation

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Co-Pay	Benefit Type
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.	We cover as medically necessary.	No plan OK needed.	All		Standard
Ambulatory Detoxification Services	Services provided to people who are withdrawing from drugs or alcohol.	We cover as medically necessary and recommended by CCP.	Plan OK needed.	All		Standard
Emergency Transportation Services	Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency.	We cover as medically necessary.	No plan OK needed.	All		Standard
Meals – Non-Emergency Transportation Daytrips	For non-emergency care when you must travel a long distance. Call CCP Member Services.	$150 per stay. Limited to 21+ years old	Plan OK needed.	Adult	$0	Expanded
Non-emergency Transportation – Non-Medical Purposes – up to 25 miles	Fees for tolls, parking and other for non-medical travel. Call CCP Member Services.	Ages 21+ years old	Plan OK needed.	Adult	$0	Expanded
Non-Emergency Transportation Services	Transportation to and from all your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles.	We cover the following services for recipients who have no transportation: Out-of-state travel Transfers between hospitals or facilities Escorts when medically necessary	No plan OK needed.	All		Standard

Service	Ambulance Transportation Services
Description	Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Ambulatory Detoxification Services
Description	Services provided to people who are withdrawing from drugs or alcohol.
Coverage / Limitations	We cover as medically necessary and recommended by CCP.
Prior Authorization	Plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Emergency Transportation Services
Description	Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency.
Coverage / Limitations	We cover as medically necessary.
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Meals – Non-Emergency Transportation Daytrips
Description	For non-emergency care when you must travel a long distance. Call CCP Member Services.
Coverage / Limitations	$150 per stay. Limited to 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Non-emergency Transportation – Non-Medical Purposes – up to 25 miles
Description	Fees for tolls, parking and other for non-medical travel. Call CCP Member Services.
Coverage / Limitations	Ages 21+ years old
Prior Authorization	Plan OK needed.
Age/Group	Adult
Co-Pay	$0
Benefit Type	Expanded

Service	Non-Emergency Transportation Services
Description	Transportation to and from all your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles.
Coverage / Limitations	We cover the following services for recipients who have no transportation: Out-of-state travel Transfers between hospitals or facilities Escorts when medically necessary
Prior Authorization	No plan OK needed.
Age/Group	All
Co-Pay
Benefit Type	Standard

Vision

Service	Description	Coverage/Limitations	Prior Authorization	Age/Group	Benefit Type
Adult Visual Aid Services	Vision aids are things like glasses or contact lenses. Call iCare at 1-877-296-0799.	Contact Lenses: 6-month supply. Frames: One (1) set of frames each year. Both include one (1) yearly eye exam.	No Plan OK needed.	Adult	Expanded
Visual Aid Services	Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes.	We cover as medically necessary when prescribed by your doctor: Two pairs of eyeglasses for children ages 0-20 One frame every two years and two lenses every 365 days for adults ages 21 and older Contact lenses Prosthetic eyes	Please call iCare at 1-877-296-0799 for OK.	All	Standard
Visual Care Services	Services that test and treat conditions, illnesses, and diseases of the eyes.			All	Standard

Service	Adult Visual Aid Services
Description	Vision aids are things like glasses or contact lenses. Call iCare at 1-877-296-0799.
Coverage / Limitations	Contact Lenses: 6-month supply. Frames: One (1) set of frames each year. Both include one (1) yearly eye exam.
Prior Authorization	No Plan OK needed.
Age/Group	Adult
Co-Pay
Benefit Type	Expanded

Service	Visual Aid Services
Description	Visual Aids are items such as glasses, contact lenses and prosthetic (fake) eyes.
Coverage / Limitations	We cover as medically necessary when prescribed by your doctor: Two pairs of eyeglasses for children ages 0-20 One frame every two years and two lenses every 365 days for adults ages 21 and older Contact lenses Prosthetic eyes
Prior Authorization	Please call iCare at 1-877-296-0799 for OK.
Age/Group	All
Co-Pay
Benefit Type	Standard

Service	Visual Care Services
Description	Services that test and treat conditions, illnesses, and diseases of the eyes.
Coverage / Limitations
Prior Authorization
Age/Group	All
Co-Pay
Benefit Type	Standard

*Funds deposited in your account and available to use with your CCP prepaid Visa when your request for this benefit is approved.

Community Care Plan is a managed care plan with a Florida Medicaid contract in Brevard, Broward, Charlotte, Collier, Desoto, Glades, Hendry, Indian River, Lee, Martin, Miami-Dade, Monroe, Okeechobee, Orange, Osceola, Palm Beach, Sarasota, Seminole, and St. Lucie counties.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the Managed Care Plan. Limitations, copayments, and/or restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change.

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