Skip Global navigation and goto content

It's a New Day in Public Health.

The Florida Department of Health works to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts.

Skip MegaMenu and goto content
Megamenu requires javascript to be enabled in your browser.
Left navigation requires javascript to be enabled in your browser.

Frequently Asked Questions

CMS Plan

  • How do pharmacies submit claims for CMS Health Plan (Operated by WellCare)?
  • Why did I receive a Notice of Termination
  • What is the Children's Medical Services (CMS) Plan?
  • Who does the CMS Plan serve?
  • Where can I find a list of CMS approved providers and facilities?
  • I see several different managed care plans listed on the Statewide Medicaid Managed Care website. How do I know if CMS is the right health care plan for my child(ren)?
  • How do I know if my child is eligible for the CMS Plan?
  • What is the process for determining if my child is clinically eligible for the CMS Plan?
  • I've already participated in a screening. Can I request a rescreening?
  • How is CMS different from the other plans participating in Medicaid Managed Care?
  • What if I am not satisfied with CMS as my plan? Can I change, and if so, how?
  • How much do I have to pay for the services my child receives from the CMS Plan?
  • What is "Prior Authorization" and do I need this to get health care services from the CMS Plan?
  • Does the CMS Plan cover medications?
  • I used to have Medicaid but was recently told that I lost my Medicaid. What happens now?
  • I am moving to another county. How do I let Medicaid know?
  • If I lose my Medicaid, can I still be enrolled in CMS?
  • My child is a lawfully residing non-citizen. Do they qualify for health insurance?

Pharmacies may submit claims to the Florida Children’s Medical Services Health Plan using the following information:

RXBIN: 004336
RXPCN: MCAIDADV
RXGRP: RX8775
Member ID Format: 10 digits, numeric
Person Code: Not required
Fax: 1-866-825-2884
Customer Service: 1-866-799-5321 (including after-hours and weekends)

I am a CMS Plan provider and I received a Notice of Termination. What does this mean?

 

On Dec. 18, 2018, the Florida Department of Health announced its intent to award WellCare with a statewide contract to implement a new service delivery model for the Children’s Medical Services Health Plan (CMS Health Plan). The Florida Department of Health (DOH) will partner with WellCare to offer the CMS Plan as of February 1, 2019. This partnership will bring about positive changes that will greatly benefit children and youth with special health care needs and providers.

 

If you are a CMS Plan provider, you may have received this message. The means that your contract with our current partner will end, but you will still be able to provide services to CMS Health Plan members for a continuity of care period. After that, you may continue to serve CMS Health Plan members under contract with WellCare.

 

Providers should not cancel appointments with current CMS Plan patients. We will honor ongoing treatment that was authorized prior to February 1st, for up to 180 days.

Providers will be paid. Providers should continue providing services that were previously authorized, regardless of whether the provider is participating in our CMS Health Plan network. We will use information provided by DOH to identify whether a member had services authorized. We will pay for these previously authorized services for up to 180 days.

Providers will be paid promptly. We will follow all timely claims payment contractual requirements.

Prescriptions will be honored. We will allow CMS Health Plan members to continue to receive their prescriptions through their current provider, for up to 180 days, until their prescriptions can be transferred to a provider in our network.

 

Provider with questions about becoming a network provider with CMS Health Plan (operated by WellCare) including credentialing, claims, and navigating our systems, should contact their Provider Relations representative. If you do not know your Provider Relations representative, you may contact FloridaProviderRelations@wellcare.com or call 1-407-551-3200, option 2.

In August of 2014, in accordance with Florida Law, CMS began operation as a
specialty managed care plan for children with special health care needs. The
purpose of the CMS Plan is to provide care to children with special health care
needs from birth up to age 21. The CMS Plan has been implemented in
collaboration with the local CMS offices, which continue to provide nurse care
coordination for our members and providers.

The CMS Plan serves Title XIX Medicaid eligible children and TXXI Florida KidCare eligible children. For specific information related to eligibility for TXXI Florida KidCare, please visit www.floridakidcare.org.

To find a CMS Plan provider near you, visit our Search Providers page.

Once you are determined to be eligible for Medicaid, you will receive information on Managed Care Plans in your region. It is your choice to be in the CMS Plan. If you do not choose a plan, Medicaid will choose a plan for you. To learn more about plan choices, click on the following link: https://flmedicaidmanagedcare.com/.

To be eligible for the CMS Plan, you must meet the following eligibility requirements:

• Be eligible for Medicaid;
• Be age 21 years or younger;
• Have chronic and serious physical, developmental, behavioral or emotional conditions as defined in Florida law;
• Require health care and related services of a type or amount beyond that which is generally required by children.

There are two ways to determine if your child is clinically eligible for the CMS Plan. Parents can either participate in a survey, or the child’s physician can attest to the child’s qualifying medical condition(s).

To participate in the parent-based survey, please call your local CMS Plan office or 1-855-901-5390.

Yes. If you have already participated in a screening, but your child was not determined to be clinically eligible for the CMS Plan, you can request a rescreening at any time. You can request a rescreening by calling your local CMS Plan office or by calling 1-855-901-5390.

CMS is designed especially to provide medically necessary services to children who have special health care needs. If your child has special health care needs, you may decide that CMS is the most appropriate plan to meet their needs. If you choose CMS as your plan, you will receive a Member Handbook which will answer many of your questions.  You will also be contacted by a CMS Registered Nurse who can assist you with any questions you have on how to get services for your child(ren).
Some Medicaid recipients may change Managed Care Plans whenever they choose, for any reason. To find out if you can change plans, call the Medicaid Choice Counselor at 1-877-711-3662 (TTY/TDD 1-866-467-4970).

There is no cost for covered services for children through a Medicaid Managed Care Plan.

Prior authorization is a process used for services that must be approved by the CMS Plan before the plan enrollee may receive them. Requests for services from your doctor will be reviewed before you can receive the service or procedure. The CMS Plan has policies and procedures to follow in making medical decisions and you will be notified in writing if your service is denied. If your service is denied, you will receive information on how to file an appeal and Medicaid Fair Hearing.

The CMS Plan covers prescription drugs when ordered by a CMS approved doctor. For a list of the prescriptions covered by the CMS Plan, please click on the following link: Florida Medicaid Preferred Drug List (PDL)

If you have questions about your Medicaid eligibility, please call the Department of Children and Families (DCF) at 1-866-762-2237 or TTY/TTD 1-800-955-8771. You may also access the following website for additional information: www.myflorida.com/accessflorida

If you move, or if your phone number changes, please call the Department of Children and Families at 1-866-762-2237 or TTY/TTD 1-800-955-8771. You may also click on the following link for additional information: https://www.myflorida.com/accessflorida/. If your child is receiving Social Security benefits, please call the Social Security Administration by calling 1-800-772-1213 or TTY/TTD 1-800-325-0778. You may also click on the following link for additional information: www.socialsecurity.gov/.

If you lose Medicaid or clinical eligibility, you will not be able to stay with the CMS Plan. If this happens, please call the Department of Health’s CMS Nurse Care Coordinator about eligibility for Florida KidCare: www.floridakidcare.org. To contact your local area office, please visit our area office contact information page.

Yes. Under a recent change in legislation, lawfully residing immigrant children in Florida are now eligible to obtain health insurance coverage without a five-year waiting period.

If your child was not eligible for health insurance coverage because of the five-year waiting period, you can reapply at any time by contacting the Florida Department of Children and Families (DCF) or Florida KidCare.

For more information regarding the new legislation or to find out if a child is eligible for coverage, please contact DCF by phone (1-866-762-2237) or visit the DCF website at www.MyFLFamilies.com. You can also contact Florida KidCare by phone (1-888-540-5437) or on their website www.FloridaKidCare.org.