What Does Florida Medicaid Cover for Seniors?

If you have a Florida Medicaid card in your wallet, you have access to one of the most comprehensive health plans in America, covering doctor visits, hospital stays, prescriptions, dental care, transportation to appointments, mental health, hearing aids, eyeglasses, family planning, and (for kids) anything medically necessary under federal EPSDT rules.

But Florida Medicaid is also a layered, three-track system: most members are enrolled in three separate plans at the same time, a medical plan, a dental plan, and (for those who qualify) a long-term care plan. Each plan covers a different slice of your benefits, comes with different rules, and is administered by different companies under contract with the Agency for Health Care Administration (AHCA).

This guide explains exactly what Florida Medicaid covers in 2026, what's included, what's not, what the limits are, and how to use the benefits you've already earned.

By Brevy Care Team · Last verified May 3, 2026

How Florida Medicaid is structured: three tracks, one card

Florida runs its Medicaid program through the Statewide Medicaid Managed Care (SMMC) system, which AHCA re-procured under "SMMC 3.0" effective February 1, 2025. The current contract cycle runs through 2030.

SMMC has three components, and most enrollees are in two or three of them simultaneously:

The medical plan is your "primary" plan for most things, the doctor's office, the hospital, the pharmacy. The dental plan is a separate enrollment that you choose alongside your medical plan. The LTC plan only applies if you need nursing-home-level care delivered at home or in an assisted living facility, and you have to qualify for it functionally and financially through a separate eligibility pathway.

If this sounds confusing, that's because it is. The good news: enrollment, plan changes, and questions are all handled by Florida's Medicaid choice counselor at 1-877-711-3662 or flmedicaidmanagedcare.com, that's the single number to call for almost anything in this article.

Who has to enroll in MMA, who chooses, and who's excluded

Florida Medicaid serves about 3.6 to 3.7 million enrollees, a number that fluctuates monthly based on AHCA's enrollment reports.

Mandatory MMA enrollment applies to most full-benefit Medicaid recipients:

• TANF-related parents/caretakers and their children
• MAGI-eligible adults and children
• SSI-related adults under age 65 not in long-term care
• Medically needy enrollees who have met their share of cost

Voluntary enrollment is open to:

• Dual-eligible Medicare and Medicaid beneficiaries (Medicare is the primary coverage; MMA functions as wraparound for the Medicaid-only services)
• American Indians and Alaska Natives (who can also keep their IHS/Tribal access)

Excluded populations (these members get state-plan acute services through fee-for-service Medicaid instead):

• Certain residents of the iBudget Developmental Disabilities waiver
• PACE program participants (PACE provides everything internally)
• Some institutionalized populations

When you enroll, you have a 120-day "change for any reason" window, pick any plan in your region, and you can switch once during those 120 days. After that, you're locked into your plan until your annual 60-day open enrollment window on the anniversary of your enrollment, unless you qualify for a "good cause" exception under Fla. Admin. Code R. 59G-8.600.

The MMA medical benefit floor

Florida law, specifically §409.973, F.S., sets a minimum benefit package that every MMA plan must cover. Plans can offer more than the minimum (and many do, as "expanded benefits"), but they can never offer less.

Here's what every MMA plan covers in 2026:

Hospital and physician care

• Hospital inpatient and outpatient services (medical, surgical, psychiatric, rehab)
• Physician services, primary care, specialists, advanced practice registered nurses (APRNs), physician assistants
• Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services, these clinics serve underserved areas and are required to be in every plan's network
• Lab and imaging, bloodwork, X-rays, ultrasounds; advanced imaging like MRI, CT, and PET typically requires prior authorization
• Emergency services, no prior authorization required, out-of-network honored, prudent-layperson standard applies

The 45-day inpatient cap question

Florida's older fee-for-service rule under §409.905(5), F.S. caps adult inpatient hospital days at 45 per year. Many older articles still cite this as a hard limit. Under MMA, this is not how it works. §409.973 requires plans to cover medically necessary inpatient days, and the 45-day cap does not function as a ceiling for managed care members. Plans use concurrent medical-necessity review. Children under 21 have no day cap at all under EPSDT (more on that below).

Maternity and pregnancy

• All prenatal and delivery care
• 12 months of postpartum coverage, Florida implemented the federal postpartum extension on April 1, 2022 under amended §409.904(4), F.S., and it remains in effect in 2026 After the 12-month postpartum period, women who lose full Medicaid coverage transition automatically into the Florida Family Planning Waiver if they meet the income criteria (more below).

Mental health and substance use treatment

Behavioral health is carved in to MMA in 2026, meaning your medical plan also covers your mental health care. Florida has not operated a separate behavioral-health-only plan since the SMMC restructuring. Covered services include:

• Outpatient therapy, psychiatric evaluations, medication management
• Intensive outpatient programs (IOP) and partial hospitalization (PHP)
• Crisis stabilization, inpatient psychiatric care
• Substance use disorder treatment, medication-assisted treatment for opioid and alcohol use disorders, ASAM-aligned residential treatment for adults

Skilled nursing facility, hospice, and home health

• Short-term skilled nursing facility stays (post-acute, after a hospital discharge), covered by MMA
• Long-term institutional placement, transitions to LTC waiver enrollment or fee-for-service institutional Medicaid; not paid by MMA
• Hospice, covers nursing visits, social work, physician services, counseling, short-term inpatient respite, durable medical equipment, home health aide, physical/occupational/speech-language therapy. The 2026 hospice per-diem rates took effect 10/1/2025 and run through 9/30/2026.
• State-plan home health, intermittent skilled nursing, home health aide, therapy. This is distinct from LTC waiver HCBS, home health under MMA is short-term, post-acute or intermittent skilled care, while LTC waiver provides ongoing personal care, homemaker services, and adult day care for members with nursing-home-level functional need.

Durable medical equipment, prosthetics, orthotics

DME, prosthetics, and orthotics are covered. Higher-cost items (typically over $750) require prior authorization per Fla. Admin. Code R. 59G-4.070.

Specialty consultation

Specialist care is covered, but you'll generally need a referral from your primary care doctor and the specialist must be in your plan's network (or you'll need a network exception).

Pharmacy benefit: $0 copays in 2026, with the PDL governing what's covered

Pharmacy is carved in to MMA, your medical plan administers your pharmacy benefit through its commercial pharmacy benefit manager (PBM, like CVS Caremark, Express Scripts, or OptumRx). But all MMA plans must comply with the AHCA-managed Florida Medicaid Preferred Drug List (PDL) and statutory step-therapy and prior-authorization rules.

The PDL is governed by AHCA's Pharmaceutical & Therapeutics (P&T) Committee under §409.91195, F.S.. The committee meets quarterly to review drug classes. The most recent quarterly PDL update took effect April 1, 2026 following the December 2025 P&T meeting. The calendar-year baseline PDL was effective January 1, 2026.

Florida Medicaid pharmacy copays in 2026: $0

Florida Medicaid members do not pay pharmacy copays in 2026. This is reaffirmed across all MMA plan member handbooks and AHCA pharmacy guidance. Florida is not currently enforcing a prescription copay, even nominal ones.

What about the old "4-prescription monthly cap"?

Florida enforced a 4-prescription-per-month brand-name limit for adults during certain budget cycles in the early 2000s under the then-current §409.906(20). This cap is not in effect in 2026. Plans manage utilization through prior authorization, step therapy, and quantity limits at the drug level, not through a member-level monthly cap.

Step therapy and prior authorization

If your doctor prescribes a non-preferred drug (one not on the PDL's preferred list), it generally requires prior authorization. Common reasons for PA:

• Brand name when a generic is preferred
• Higher tier within a drug class
• High-cost biologics, oncology agents, GLP-1 medications, hepatitis C antivirals, HIV regimens, specialty injectables

If your PA is denied, you have appeal rights through your plan, then through a Medicaid Fair Hearing (more in the appeals section below).

Specialty pharmacy

Plans contract with specialty pharmacy networks (Accredo, BriovaRx, Acaria) for biologics, oncology orals, and other high-cost or temperature-sensitive drugs. Your prescriber will be told if a drug must be filled at a specialty pharmacy.

Non-Emergency Medical Transportation (NEMT)

If you can't drive yourself to a Medicaid-covered medical appointment, your MMA plan covers transportation. NEMT is carved in to MMA, each plan contracts its own transportation broker. AHCA does not run a single statewide NEMT broker contract.

The two dominant brokers serving Florida MMA plans are ModivCare (formerly LogistiCare) and MTM Health. Access2Care holds limited contracts. As of 2026, UnitedHealthcare Community Plan FL transitioned to MTM Health effective March 1, 2026. Other plans use ModivCare or their own contracted brokers, verify with your plan.

How to use NEMT

• Call your plan's transportation broker at least 3 business days before your scheduled appointment
• The broker number is on your plan's member ID card or in your member handbook
• For same-day urgent transports (e.g., post-discharge), the broker may accommodate but it's at their discretion

What modes are covered

• Public transit bus pass (if you can use it)
• Sedan or taxi
• Wheelchair-accessible van
• Stretcher van
• Air ambulance (rare, medical necessity required)
• Mileage reimbursement to a family member or friend who drives you (some plans only)

NEMT is operationally governed by Fla. Admin. Code R. 59G-4.330.

What NEMT doesn't cover

• Trips to non-Medicaid services (e.g., grocery shopping, social visits)
• Emergencies, call 911 instead, ambulance services are covered separately as emergency transport
• Trips outside Florida unless pre-approved for out-of-state covered care

Dental coverage: a separate plan, expanded benefits for adults

Here's the part that confuses the most members: your MMA plan does not cover dental care. Dental is delivered through the separate Statewide Medicaid Prepaid Dental Health Program (PDHP).

Under SMMC 3.0, the PDHP statewide plans are DentaQuest (member services 1-888-468-5509) and Liberty Dental Plan of Florida (member services 1-833-276-0850). A third plan, MCNA Dental, held the prior cycle's contract, and some AHCA consumer-facing pages still reference MCNA, call AHCA at 1-877-254-1055 or check flmedicaidmanagedcare.com/Home/dentalplans to confirm currently participating plans before assuming who you'll be enrolled with.

You enroll in your dental plan separately from your MMA plan. The choice counselor at 1-877-711-3662 handles both enrollments.

Adult dental (age 21+)

Florida historically provided emergency-only adult dental, limited to extractions and dentures. Under SMMC's PDHP, adults now receive all state-plan dental services:

• Exams and screenings
• X-rays
• Extractions
• Plus expanded benefits with prior approval, which often include cleanings, fillings, root canals, periodontal services, and dentures

Expanded benefit dollar caps vary by plan, typical adult expanded-benefit annual maximums run $1,000 to $1,500 for cleanings and restorative services. Check your specific plan's member handbook.

Child dental (under 21)

Under EPSDT, kids get comprehensive medically necessary dental services with no annual maximum, including orthodontia when medically necessary. Routine cleanings, fillings, root canals, sealants, and emergency care are all covered without dollar limits.

What's not covered

• Adult orthodontia is generally not a covered benefit
• Cosmetic dentistry (whitening, veneers) is not covered

Vision and hearing

Vision

Adult vision under the state-plan baseline:

• One routine eye exam per year
• One pair of eyeglasses every two years

Most MMA plans expand this to annual eyeglasses as a plan-level expanded benefit. Check your plan's vision benefit page.

Child vision under EPSDT:

• Comprehensive, exams, glasses, replacement glasses as medically needed
• No biennial cap

Hearing

Per Fla. Admin. Code R. 59G-4.110, Florida Medicaid covers for adults:

• One hearing assessment per 3 years
• One new (not refurbished) hearing aid per ear, every 3 years for moderate hearing loss or greater
• Up to 3 pairs of ear molds per year
• One fitting and dispensing service per ear, every 3 years
• Repairs and replacement of both Medicaid-provided and non-Medicaid-provided hearing aids

Children under EPSDT get comprehensive medically necessary hearing services without the 3-year cycle limits.

EPSDT: the federal mandate that makes child Medicaid the most generous benefit in America

EPSDT, Early and Periodic Screening, Diagnostic and Treatment, is the federal Medicaid mandate for members under 21. Florida calls it the Child Health Check-Up program.

What EPSDT requires

Under §1905(r) of the Social Security Act, Medicaid must cover anything medically necessary to correct or ameliorate a physical or mental condition for members under 21, even if the service is not in the adult state plan.

This means kids on Medicaid are entitled to:

• Comprehensive screening: physical exams, vision, hearing, dental, developmental, behavioral
• Immunizations per the ACIP schedule
• All medically necessary diagnostic and treatment services
• Services not otherwise covered for adults: Applied Behavior Analysis (ABA) therapy for autism, dental orthodontia for medical necessity, expanded behavioral health, intensive in-home services

Periodicity schedule

Visits are scheduled per the American Academy of Pediatrics Bright Futures schedule:

• Ages 0–2: visits at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months
• Ages 3–20: annually

Your child's pediatrician handles these visits. If you've changed plans or providers, the new plan's care coordinator can pull records and ensure the schedule is met.

Family Planning Waiver: bridge coverage for women losing Medicaid

When a woman loses full Medicaid coverage, for instance, after the 12-month postpartum period ends, or after a household income increase, she may still qualify for the Florida Family Planning Waiver under a Section 1115 demonstration that CMS most recently extended on April 30, 2025.

Who qualifies

• Women ages 14 to 55
• Family income at or below 191% FPL (2026 limit)
• Not otherwise eligible for full Medicaid, CHIP, or other coverage providing family planning

How long the coverage lasts

Up to 24 months following loss of full Medicaid eligibility. Postpartum women losing pregnancy Medicaid coverage transition automatically into the Family Planning Waiver if they meet the criteria.

What's covered

• All FDA-approved contraceptive methods, including long-acting reversible contraception (LARC), IUDs, implants
• Sterilization (with required federal consent forms)
• Family-planning-related counseling, education, risk reduction
• Family-planning-related lab work, pregnancy testing, STI testing and treatment when family-planning related
• Limited primary care needed to provide family planning safely

What's not covered under the waiver

• Comprehensive primary care
• Abortion services (per the Hyde Amendment and Florida law)
• Hysterectomy for sterilization purposes
• Infertility services

Specialty plans for complex populations

Florida operates several specialty plans within MMA targeting populations with specific complex needs:

Specialty plans aren't enrollment-by-default, eligibility is established through clinical or administrative criteria, and the choice counselor will let you know if you qualify. Healthy Start, Florida's voluntary maternal/infant care coordination program, is a separate enhanced service operated by local Healthy Start Coalitions, not an MMA carve-out.

Cost sharing: what (very little) you'll pay out of pocket

Florida Medicaid is among the lowest-cost-sharing programs in America. There are no member premiums for MMA. Florida KidCare (CHIP) is a separate program with sliding-scale family premiums and is not part of MMA.

Service copays

Florida's nominal service copays under §409.9081, F.S.:

• $3 for non-emergency use of an emergency department
• $2 per outpatient hospital service
• $2 per physician visit
• $0 for preventive services

In practice, most MMA plans waive nominal copays as an enrollment-marketing strategy. Check your plan's member handbook.

Pharmacy copays

$0, Florida Medicaid does not enforce pharmacy copays in 2026.

Copay-exempt populations

Federal and state rules exempt the following groups from cost sharing:

• Children under 21
• Pregnant women through the 12-month postpartum period
• Members in hospice
• Nursing facility residents
• LTC waiver participants (institutional-deemed financial status)
• American Indians/Alaska Natives receiving care via IHS, Tribal, or Urban Indian Organization providers
• Family planning services (no copay)
• Emergency services

Service limits to know

• Outpatient hospital: historic $1,500/year FFS adult cap; MMA plans typically waive this
• Therapy visits (PT, OT, ST): Fla. Admin. Code 59G-4.295 family rules historically run ~35 visits per discipline per year for adults; MMA plans may apply medical-necessity review beyond the floor; children unlimited under EPSDT
• Inpatient days: the 45-day FFS cap does not function as a hard ceiling for MMA members; plans use medical-necessity review

Common prior-authorization triggers

• MRI, CT, PET imaging
• DME items above ~$750 cost threshold
• Out-of-network specialty care
• Bariatric surgery, gender-affirming services, organ transplants
• Home health beyond initial visits
• Inpatient behavioral health (concurrent review)
• Non-preferred PDL drugs

Appeals and grievances: a three-level pathway

If your MMA plan denies, reduces, or terminates a service, you have appeal rights at three levels.

Level 1: Plan grievance and appeal

You must first file with your MMA plan within 60 days of the Notice of Adverse Benefit Determination (NABD). The plan must:

• Resolve standard appeals within 30 days
• Resolve expedited appeals (when waiting could seriously jeopardize your health) within 72 hours
• Allow you to continue benefits during appeal if you request continuation timely

If the plan upholds its denial, you can move to Level 2.

Level 2: Medicaid Fair Hearing

You can request a Medicaid Fair Hearing with the Florida Department of Children and Families (DCF) Office of Appeal Hearings within 120 days of the plan's appeal resolution. (The federal mandate is at least 90 days from the NABD; Florida provides 120.)

• Hearings can be in person, by phone, or by video
• Decisions are binding on the plan
• You can represent yourself or have an attorney, family member, or advocate

Level 3: Subscriber Assistance Program (SAP)

Under §408.7056, F.S., Florida operates a Subscriber Assistance Program, a statewide panel that reviews grievances against managed care entities.

• File within 365 days of the plan's final decision
• Panel issues written recommendation within 15 working days of the hearing
• SAP cannot review matters under active Medicaid Fair Hearing or Medicare grievances, these pathways are mutually exclusive at the same time

Federal MCO appeal timelines

The federal regulations governing Medicaid managed care appeals are at 42 CFR 438.402 and 438.408.

Continuity of care during appeals

If you request continuation of services during your appeal within the timely-filing period, the plan must maintain services pending the appeal decision. Important caveat: if the appeal is upheld against you, the plan may recoup the cost of those continued services from you.

Help with appeals

• AHCA Medicaid Helpline: 1-877-254-1055, assists with complaints
• Florida Health Justice Project, publishes consumer-friendly appeals guides at floridahealthjustice.org
• Florida Senior Legal Helpline (age 60+): 1-888-895-7873, free legal advice
• Disability Rights Florida, for members with disabilities

What's changed in 2026, and what to watch

A few benefit-relevant updates to know:

• SMMC 3.0 is in full operation; second contract year underway
• Continuity of care rules tightened, plans must temporarily honor active treatments and provider relationships during plan transitions; protected populations include pregnant, oncology, transplant, complex pediatrics, behavioral health
• Adult dental expansion continues under PDHP with DentaQuest and Liberty
• 12-month postpartum coverage continues (in effect since 4/1/2022)
• Family Planning Waiver extension approved 4/30/2025 by CMS
• CMS Health Plan transition to Molina with target go-live 10/1/2026
• Family Home Health Aide (FHHA) Services Program for medically fragile children added under MMA 1115 amendment, paid family caregivers serving as home health aides for qualifying children
• PDL update effective 4/1/2026

Florida's 2026 legislative session also produced HB 697, HB 915, and SB 40, verify final dispositions and effective dates with the Florida Senate or House before relying on any specific 2026 legislative change.

Common confusions about Florida Medicaid coverage

Even members who've had Medicaid for years run into these misunderstandings:

Underutilized benefits to ask about

These are real, in-effect benefits that members commonly don't use because they don't know they exist:

• Expanded dental benefits for adults, cleanings, fillings, dentures with prior approval
• Annual eyeglasses as an MMA plan expanded benefit
• Plan over-the-counter (OTC) allowances for non-prescription drugs and health products, many plans give a monthly OTC budget
• Care coordinator and case management for chronic conditions like diabetes, COPD, heart failure
• Smoking cessation counseling and pharmacotherapy
• Doula services, some plans added these as expanded benefits in 2024–2025
• Healthy Behaviors rewards programs, gift cards for completing well-child visits, screenings, prenatal care
• Telehealth, broadly covered including audio-only visits post-PHE

Call your plan's member services number (on your ID card) and ask about expanded benefits in your plan year. Plans differentiate themselves on these benefits, so they want you to know about and use them.

Frequently asked questions

Bottom line

Florida Medicaid in 2026 is a comprehensive program covering doctors, hospitals, prescriptions ($0 copay), mental health, dental (separate plan), vision, hearing, transportation to appointments, family planning, maternity care with 12-month postpartum, and, for kids, anything medically necessary under EPSDT.

The benefits are organized across three tracks: MMA for medical, PDHP for dental, and (for those who qualify) LTC for long-term services. Most members enroll in two of these three plans. The choice counselor at 1-877-711-3662 is your entry point for almost every question, change, or enrollment.

If you've been on Medicaid for a while and never used your dental, vision, or hearing benefits, call your plans. If you've been denied a service, file an appeal. If you've lost full Medicaid, ask about the Family Planning Waiver. The benefits are yours, and Florida's program runs on the assumption that members will use them.

Need help navigating your Florida Medicaid benefits?

• Choice counselor / plan enrollment / plan change: 1-877-711-3662 or flmedicaidmanagedcare.com
• AHCA Medicaid Helpline (complaints, fair hearings): 1-877-254-1055
• Elder Helpline (age 60+): 1-800-963-5337
• Florida Senior Legal Helpline (free legal advice age 60+): 1-888-895-7873
• DentaQuest member services: 1-888-468-5509
• Liberty Dental Plan member services: 1-833-276-0850
• DCF ACCESS Florida (financial eligibility): 1-866-762-2237 / dcf.myflorida.com/access
• VA Caregiver Support Line (for veterans and their caregivers): 1-855-260-3274 Find personalized help navigating Florida Medicaid at brevy.com.