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Medical and Behavioral Health Coverage Policy

The Medical and Behavioral Health Coverage Section is made up of the Primary and Preventative Care Policy and Facilities, Behavioral Health, and Specialized Health Services units.  These units develop policy, procedures and programs focused on physician’s services, organ transplant services, inpatient and outpatient hospital services, durable medical equipment, hearing, vision and dental services, chiropractic and podiatric services, behavioral health services, independent laboratory services, transportation services and services to improve children’s health.

Primary and Preventive Care Policy

The Primary & Preventive Care Policy unit develops policy for procedures and programs focused on services furnished by the following professional practitioners and facilities:  physicians, advanced registered nurse practitioners, physician assistants, registered nurse first assistant; anesthesiology assistants, radiologists, midwives, birth centers, podiatrists, chiropractors, opticians, optometrists, hearing services providers, independent labs, portable x-ray, County Health Department, Federally Qualified Health Centers, Rural Health Clinic, Regional Perinatal Intensive Care Centers, dialysis services, organ and tissue transplants, nursing facility services, intermediate care facility services for the developmentally disabled (ICF/DD), inpatient and outpatient hospital services and ambulatory surgical centers.  

Health Care Policy Research

Responsible for the development of informed coverage decisions based on sources of reliable evidence by researching new or emerging health services.

Determining Generally Accepted Professional Medical Standards (GAPMS)

Medicaid coverage determinations are made when all criteria of medical necessity are met. Florida Medicaid must determine if a diagnostic test, therapeutic procedure, or medical device or technology is experimental or investigational, as one of the components of the medical necessity criteria.

Specialized Health Services Policy

The Specialized Health Services Unit is responsible for developing policy and administering the following programs: therapy services, home health, hospice, durable medical equipment and supplies and transportation. In addition, the Specialized Health Services Unit oversees prescribed pediatric extended care, medical foster care, early intervention services, assistive care services, private duty nursing and personal care services. Other services include Medicaid certified school match, school district administrative claiming, and county health department certified match policy.

Behavioral Health and Behavior Analysis

The Behavioral Health and Behavior Analysis unit develops policy, procedures, and programs for behavioral health, including mental health and substance abuse, and behavior analysis, also known as applied behavior analysis. This unit oversees community behavioral health services (CBHS), which include assessments, psychotherapy, community support and intervention services, and medication management; specialized therapeutic services (STS), which includes comprehensive behavioral health assessment and therapeutic group care; substance abuse outpatient services; statewide inpatient psychiatric program services for children (SIPP); state mental health hospital services; and targeted case management services.

Specific Service Information

Individual service coverage policies are available on the Agency’s Service Policy webpage.

Reimbursement information is available on the Agency’s Reimbursement Policy webpage and the Reimbursement Schedules webpage.