Florida Benefits Description (CHIP and Medicaid)

State Contact: FloridaKidCare Customer Service

Telephone Number: 800-821-5437

E-mail Address: FHKSupport@acs-inc.com

CHIP Program

CHIP Medicaid Expansion and Stand-Alone Program (dental services are as described above)

State Program Name: 

Florida KidCare Program – for the Healthy Kids program, a Title XXI program component of the Florida KidCare program only, only for children ages 5 through 18

If providing dental benefits other than as defined by EPSDT, States must complete the following:

CHIP Stand-Alone Program Dental Benefits for Healthy Kids Program Component only

NOTE: Please identify any limits or other criteria using terms commonly recognized by individuals without extensive oral health terminology knowledge rather than using technical dental terminology. For example, use molar rather than posterior, or front versus anterior.

Nationally Recognized Standard
Name and Description: Same benefits as provided under Florida Medicaid for children.

Preventive Services:

• Cleanings
  Recommended frequency: Every 6 months
• Fluoride treatments
  Ages: 5-18
  Recommended frequency: Every 6 months
• Sealants
  Ages: 5-18
  Recommended frequency: Every 3 years.
  Exceptions: Limited to one application per tooth every 3 years; permanent teeth only
• Oral hygiene instruction
  Ages: 5-18
  Recommended frequency: As often as needed
• Space Maintainers
  Limits: Limited to fixed appliances, must be passive and be maintained for at least six months
  Prior approval required.

Diagnostic Services:

• Dental Examinations by Dentists
  Recommended age of first visit: NA – Healthy Kids services children 5-18
  Recommended frequency: Every 6 months
  Limits: Limited to once every 6 months.
• Dental Screens and Other Services by Hygienists
  Recommended frequency:
  Limits:
• X-Rays
  Limits: Complete set of intraoral limited to once every 3 years. Bitewings every 6 months. A panoramic is limited to once per year.

Treatment Services:

• Fillings
  1. Silver amalgam:
     Limits: One restoration per tooth surface except for the occlusal surface of permanent max. 1st and 2nd molars. One restoration for a mesial or distal lesion.
  2. Tooth colored composite:
     Limits: One posterior one-surface resin restoration (D2391) every 3 years per tooth number or letter per tooth surface. Both permanent and primary teeth are included.
• Crowns/Tooth Caps
  1. Stainless steel crowns:
     Limits:
     Prior approval required: No
  2. Metal/Porcelain crowns:
     Limits: Permanent posterior teeth when the tooth has been treated endodontically and cannot be adequately restored with a stainless steel crown, amalgam, or resin. Permanent anterior teeth when the tooth cannot be adequately restored with a resin restoration.
     Prior approval required: No
• Root Canals (endodontics)
  1. Root canals on baby teeth (Pulpotomies):
     Limits: Covered only if one of the following conditions exist: overfilled canal or canal cannot be filled due to excess root curvature; fractured root tip is not reachable; broken instrument in canal; perforation of the root in the apical one-third of the canal; root canal filling material lying free in tissues and acting as an irritant; or periapical pathology not resolved by root canal therapy.  Root canal on primary teeth with succedaneous teeth must include the placement of a restorable filling.
     Prior approval required: No
  2. Root canals on permanent teeth:
     Limits: Covered only if one of the following conditions exist: overfilled canal or canal cannot be filled due to excess root curvature; fractured root tip is not reachable; broken instrument in canal; perforation of the root in the apical one-third of the canal; root canal filling material lying free in tissues and acting as an irritant; or periapical pathology not resolved by root canal therapy.  Root canal on primary teeth with succedaneous teeth must include the placement of a restorable filling.  All dental services limited to $1,000 dental benefit cap.
     Prior approval required: No
• Gum (periodontal) Therapy
  Limits: Child must have pockets in excess of the 4 to 5 mm. range.
  Prior approval required: No
• Dentures
  1. Partial dentures:
     Prior approval required: No
     Partial dentures are not covered if the child has at least 8 posterior teeth in occlusion. 
  2. Complete dentures:
     Prior approval required: No
     Provided once for an upper, a lower or a complete set per the child’s lifetime.
• Retainers (orthodontic)
  Limits: Orthodontics limited only to those circumstances where the child’s condition creates a disability and is an impairment to the physical development. Monthly maintenance visits are limited to 24 months. Services are not covered for limited or interceptive treatment; primarily cosmetic services; or split phase treatment with the exception of cleft palate cases.
• Oral Surgery
  1. Simple extractions:
     Limits:
     Prior approval required: No
  2. Surgical extractions:
     Limits:
     Prior approval required: No
  3. Care of abscesses:
     Limits:
     Prior approval required: No
  4. Cleft palate treatment:
     Limits:
     Prior approval required:
  5. Cancer treatment:
     Limits:
     Prior approval required: No
  6. Treatment of Fractures:
     Limits: These services may also fall under medical services where the treatment is due to an accident or injury to the mouth.
     Prior approval required: No
  7. Biopsies:
     Limits: All dental benefits limited to $1,000 annual benefit cap. These services may also fall under medical services and be covered through the separate medical services contracts which do not include a dental benefit limit.
     Prior approval required:

• Braces (Orthodontia)
  Criteria: Orthodontics limited only to those circumstances where the child’s condition creates a disability and is an impairment to the physical development. Monthly maintenance visits are limited to 24 months. Services are not covered for limited or interceptive treatment; primarily cosmetic services; or split phase treatment with the exception of cleft palate cases.
  Prior approval required: No
  Payment if eligibility lost: No
• Emergency Room Services
  Identify services: These services may also fall under medical services and be covered through the separate medical services contracts depending on the nature of the injury and services needed.
• In-patient Hospital Services
  Criteria: These services may also fall under medical services and be covered through the separate medical services contracts depending on the treatment needed and the nature of the injury.
• Special Anesthesia (Healthy Kids: Hospitalization for dental treatment)
  Criteria: Child’s health must be so jeopardized that the procedures cannot be safely performed in the office and/or the child is so uncontrollable due to emotional instability or developmental disability and other sedation has been ineffective.

• Excluded Services

  1. Services are delivered through one of our two statewide dental plans. These plans do offer a minimum discount of 25% off the provider’s usual and customary fees for services beyond any benefit maximum or for services that are otherwise uncovered.
  2. Additionally, within each of the dental plans, there may be prior authorization or approval processes for some services. These are managed by each dental plan, not the Healthy Kids program, and must meet federal requirements for prior authorization processes. Most prior authorization processes are for specialty services or where a referral to a specialist may be required.