In Lieu of Services resource guide
Helping you connect members to behavioral health care
Simply Health Plans, Inc. partners with you to support the physical and behavioral health of our Statewide Medicaid Managed Care Managed Medical Assistance (SMMC MMA) member. Our In Lieu of Services (ILOS) plan offers clinically appropriate, cost-effective alternatives to certain standard Medicaid-covered services.
Members and their care providers may choose either the standard Medicaid benefit or an ILOS option when it is clinically appropriate. Document the selected service in the member’s clinical record if an ILOS is used.
Our guide explains available ILOS benefits, eligibility criteria, limits, and prescribing or authorization rules. For questions or assistance, please contact Provider Services at 1-844-405-4296.
In lieu of: Inpatient psychiatric care
Service limits
Up to 45 days per fiscal year for members age 21 years and older. For IMD facilities, limited to 15 days per admission.
Service type
Behavioral health crisis stabilization in CSU and freestanding psychiatric specialty hospitals.
Prior authorization
Services provided under the Baker Act are not subject to prior authorization.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Crisis Stabilization Units (CSU) and freestanding psychiatric specialty hospitals.
Procedure code(s)
S9485
Prescribing rules/coverage requirements
Services must meet crisis-level medical necessity criteria. Limits apply as above; for IMD facilities, coverage is limited to 15 days per admission, in accordance with applicable Baker Act rules.
In lieu of: Inpatient detoxification hospital care
Service limits
Up to 45 days per fiscal year for members aged 21 years and older. For IMD facilities, limited to 15 days per admission.
Service type
Residential detoxification in licensed detoxification or addiction receiving facilities.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Detoxification or addiction-receiving facilities licensed under section 397, Florida Statutes.
Procedure code(s)
Revenue code 126
Prescribing rules/coverage requirements
Services must be medically necessary for detoxification. Coverage is limited to 45 days per fiscal year (age 21 and over) and, for IMD facilities, to 15 days per admission. Applicable Marchman Act requirements apply.
In lieu of: Emergency behavioral healthcare
Service limits
1 unit = 15 minutes; maximum of 8 units per day. No annual limit.
Service type
Mobile crisis behavioral health assessment and intervention.
Prior authorization
No.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Mobile crisis team providers.
Procedure code(s)
H2011HO
Prescribing rules/coverage requirements
Service is provided in the community to stabilize behavioral health crises and avoid emergency room visits or inpatient admission. Units and daily limits must align with the 15-minute unit structure and 8-unit maximum per day.
In lieu of: Inpatient detoxification hospital care
Service limits
3 hours per day, up to 60 days annually.
Service type
Ambulatory (outpatient) detoxification services.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Outpatient/ambulatory detoxification providers.
Procedure code(s)
S9475
Prescribing rules/coverage requirements
Used as a less restrictive alternative to inpatient detoxification when medically appropriate. Coverage is limited to the daily and annual limits described above.
In lieu of: Psychosocial rehabilitation
Service limits
1 unit = 15 minutes; up to 16 units per day (maximum of 4 hours per day), with a total of 40 hours per year.
Service type
Peer support and self-help behavioral health services.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Individuals qualified by training and certification to provide peer/self-help services under the supervision of a licensed master’s level clinician.
Procedure code(s)
H0038
Prescribing rules/coverage requirements
Services support recovery, self-management, and community integration, and must meet medical necessity criteria within the defined annual hour and daily unit limits.
In lieu of: Clubhouse
Service limits
Unit of service is per diem; no annual limit (per Exhibit II A MMA Program Feb 1, 2018, page 32, Item 2.g.(3)).
Service type
Behavioral health drop-in center services.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Clubhouse providers.
Procedure code(s)
S5102HE
Prescribing rules/coverage requirements
Drop-in center services must meet medically necessary criteria and function as an alternative to traditional clubhouse services, providing structured support and recovery-oriented activities.
In lieu of: Psychological testing
Service limits
Unit of service is 15 minutes. For children ages 0 through 5, limited to 40 units per year.
Service type
Infant and early childhood mental health testing and assessment.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: 5
Provider type
Independently licensed providers or those under supervision with at least two years of part-time or greater experience with the population served.
Procedure code(s)
T1023HA
Prescribing rules/coverage requirements
Used to support diagnostic clarification and treatment planning for infants and young children. Coverage is limited to the stated annual unit cap.
In lieu of: Therapeutic behavioral on-site services
Service limits
Unit of service is 15 minutes; limit of 16 units per day, for a maximum of 30 days per year.
Service type
Family training and counseling to support child development and behavior.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria; typically child/family focused)
Provider type
Bachelor’s level practitioner.
Procedure code(s)
T1027
Prescribing rules/coverage requirements
Services focus on family education, skill-building, and support, rather than more intensive on-site therapeutic services. Limits apply to daily units and annual days.
In lieu of: Therapeutic group care services or statewide psychiatric program services
Service limits
Unit of service is per diem, up to four months of treatment; no annual limit for children under age 21.
Service type
Community-based wraparound care coordination and support.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (focus on children, especially under 21)
Provider type
Provider Type 91 and certified to provide children’s wraparound services; providers must have completed SAMHSA training on wraparound services.
Procedure code(s)
H2022
Prescribing rules/coverage requirements
Services are designed to maintain children in the community and avoid higher levels of care (such as group care or SIPP). Limits apply to treatment duration as specified.
In lieu of: Inpatient detoxification hospital care
Service limits
May be billed daily, up to four days per week, for nine weeks.
Service type
Substance use disorder (SUD) intensive outpatient treatment.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Community Mental Health Centers and/or community behavioral health providers.
Procedure code(s)
H0015
Prescribing rules/coverage requirements
Intensive outpatient services must meet SUD medical necessity criteria and are used as an alternative to inpatient detox where clinically appropriate, following the frequency and duration limits above.
In lieu of: Inpatient detoxification hospital care
Service limits
Up to 30 days annually.
Service type
Short-term residential substance use treatment.
Prior authorization
Yes.
Eligible members
- Minimum age: 0
- Maximum age: No stated maximum (all ages, subject to Clinical Criteria)
Provider type
Residential treatment facilities.
Procedure code(s)
H0018
Prescribing rules/coverage requirements
Services must meet residential SUD medically necessary criteria and are limited to 30 days per year as an alternative to inpatient detoxification.
In lieu of: Inpatient and residential stay or SIPP
Service limits
Up to 30 days annually.
Service type
Evidence-based, intensive in-home behavioral health treatment (MST).
Prior authorization
Yes.
Eligible members
- Minimum age: 12
- Maximum age: 17
Provider type
Community mental health centers and/or community behavioral health providers.
Procedure code(s)
H2033
Prescribing rules/coverage requirements
MST is provided in lieu of inpatient or residential placement for eligible youth, based on MST Clinical Criteria and medically necessary.
In lieu of: Emergency department visit or inpatient hospitalization for SMI and/or SUD
Service limits
Various, depending on service criteria and requirements.
Service type
Housing assistance and supports for members with serious mental illness (SMI) and/or substance use disorder (SUD).
Prior authorization
No.
Eligible members
- Minimum age: 21
- Maximum age: 99
Provider type
Community mental health centers and/or community behavioral health providers.
Procedure code(s)
H0043 HK (Transitional Housing Services) and H2015 HK (Tenancy Sustaining Services)
Prescribing rules/coverage requirements
Targeted to members with SMI or SUD who are homeless or at risk of homelessness. Service requirements and limits vary based on program criteria.
In lieu of: Emergency department visits or inpatient hospitalization
Service limits
Service limits follow plan guidelines and evidence-based model criteria.
Service type
Functional Family Therapy (FFT) in home or community settings for youth with justice involvement or at high risk for justice involvement.
Prior authorization
Refer to current plan authorization requirements; prior authorization may be required.
Eligible members
- Minimum age: 11
- Maximum age: 18
Provider type
Functional Family Therapy providers contracted with Simply.
Procedure code(s)
H0036
Prescribing rules/coverage requirements
Services must adhere to FFT model standards and are intended to reduce the risk of higher levels of care or justice system involvement.
In lieu of: Inpatient psychiatric hospital care
(Both services treat members who would otherwise require inpatient psychiatric hospital care but can be safely treated in a partial hospital program and return home the same day.)
Service limits
- Mental Health Partial Hospitalization Program (PHP – H0035): Up to 90 days annually for adults; unlimited for children.
- Hospital-Based Partial Hospitalization (0912): Up to 30 days annually.
Service type
Partial hospitalization/day treatment services in hospital-based or community settings.
Prior authorization
Yes (for both H0035 and 0912).
Eligible members
- Minimum age: 13
- Maximum age: No maximum age (adolescents and adults)
Provider type
- Partial hospital programs – hospital-based
- Community mental health centers and/or community
Procedure code(s)
H0035 (CPT code) and 0912 (Rev Code)
Prescribing rules/coverage requirements
Services are provided as an alternative to inpatient psychiatric hospitalization when the member can safely return home after daily treatment. Coverage and duration must follow the limits above and meet medical necessity criteria for partial hospitalization.