Fill - Free fillable Child Welfare Speciatly Plan Member Handbook (Sunshine Health) PDF form

October 2020

Quest

ions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

“If you do not speak English, call us at 1-855-463-4100. We have access to interpreter

services and can help answer your questions in your language. We can also help you find a

health care provider who can talk with you in your language."

Spanish: Si usted no habla inglés, llámenos al 1-855-463-4100. Ofrecemos servicios de

interpretación y podemos ayudarle a responder preguntas en su idioma. También podemos

ayudarle a encontrar un proveedor de salud que pueda comunicarse con usted en su

idioma.

French: Si vous ne parlez pas anglais, appelez-nous au 1-855-463-4100. Nous avons

accès à des services d'interprétariat pour vous aider à répondre aux questions dans votre

langue. Nous pouvons également vous aider à trouver un prestataire de soins de santé qui

peut communiquer avec vous dans votre langue.

Haitian Creole: Si ou pa pale lang Anglè, rele nou nan 1-855-463-4100. Nou ka jwenn sèvis

entèprèt pou ou, epitou nou kapab ede reponn kesyon ou yo nan lang ou pale a. Nou kapab

ede ou jwenn yon pwofesyonèl swen sante ki kapab kominike avèk ou nan lang ou pale a."

Italian: "Se non parli inglese chiamaci al 1-855-463-4100. Disponiamo di servizi di

interpretariato e siamo in grado di rispondere alle tue domande nella tua lingua. Possiamo

anche aiutarti a trovare un fornitore di servizi sanitari che parli la tua lingua."

Russian: «Если вы не разговариваете по-английски, позвоните нам по номеру 1-

855-463-4100. У нас есть возможность воспользоваться услугами переводчика, и мы

поможем вам получить ответы на вопросы на вашем родном языке. Кроме того, мы

можем оказать вам помощь в поиске поставщика медицинских услуг, который может

общаться с вами на вашем родном языке».

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

I Important Contact Information

Member Helpline

1-855-463-4100

Available 24 hours

Member Help Line TTY

1-800-955-8770

Available 24 hours

Website

SunshineHealth.com

Address

P.O. Box 459089

Fort Lauderdale, FL 33345-9089

Service

Contact Information

Logisticare

(Transportation)

Reservations: 1-877-659-8420

Ride Assist (Where’s My Ride?): 1-877-659-8421

HearUSA

(Hearing Services)

1-800-442-8231

Florida Care Management

Services Agency (Long-Term

Care Case Management)

1-877-462-1200

GT Independence

(Long-Term Care PDO)

1-877-659-4500

Envolve PeopleCare 24-Hour

Nurse Advice Line

1-855-696-2553

Envolve PeopleCare Nurtur

(Disease Management)

1-800-942-4008

Envolve Pharmacy Solutions

(Pharmacy Services)

1-800-460-8988

Dental Services

Contact your case manager directly or call

1-855-463-4100 for help with arranging these

services.

To report suspected cases of

abuse, neglect, abandonment,

or exploitation of children or

vulnerable adults

1-800-96-ABUSE (1-800-962-2873)

TTY: 711 or 1-800-955-8771

http://www.myflfamilies.com/service-

programs/abuse-hotline

For Medicaid Eligibility

1-866-762-2237

TTY: 711 or 1-800-955-8771

http://www.myflfamilies.com/service-

programs/access-florida-food-medical-assistance-

cash/medicaid

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Contact Information

To report Medicaid Fraud

and/or Abuse or to file a

complaint about a health care

facility

1-888-419-3456

https://apps.ahca.myflorida.com/mpi-

complaintform/

To request a Medicaid Fair

Hearing

1-877-254-1055

1-239-338-2642 (fax)

MedicaidHearingUnit@ahca.myflorida.com

To file a complaint about

Medicaid services

1-877-254-1055

TTY: 1-866-467-4970

https://ahca.myflorida.com/Medicaid/complaints/

To report Medicaid Fraud

and/or Abuse

1-888-419-3456

https://apps.ahca.myflorida.com/mpicomplaintform/

To file a complaint about a

health care facility

1-888-419-3450

http://ahca.myflorida.com/MCHQ/Field_Ops/CAU.s

html

To find information for elders

1-800-96-ELDER (1-800-963-5337)

http://elderaffairs.state.fl.us/doea/arc.php

To find out information about

domestic violence

1-800-799-7233

TTY: 1-800-787-3224

http://www.thehotline.org/

To find information about

health facilities in Florida

http://www.floridahealthfinder.gov/index.html

To find information about

urgent care

Call Member Services, check your Sunshine

Health Provider Directory, or go to

SunshineHealth.com and click “Find A Provider.”

For an emergency

9-1-1

Or go to the nearest emergency room

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Table of Contents

Section 1: Your Plan Identification Card (ID card)................................ Page 10

Section 2: Your Privacy .......................................................................... Page 11

Covered Sunshine Duties .......................................................................... Page 11

How We Use or Share Your Health Records .................................. Page 12

Uses and Releases of Your Health Records

That Require Your Written Consent ................................................ Page 14

Member Rights ............................................................................... Page 14

Contact Information ........................................................................ Page 16

Section 3: Getting Help from Our Member Services ............................ Page 16

Contacting Member Services.......................................................... Page 16

Contacting Member Services After Hours ...................................... Page 16

Section 4: Do You Need Help Communicating? ................................... Page 17

Section 5: When Your Information Changes ........................................ Page 17

Section 6: Your Medicaid Eligibility ....................................................... Page 17

If you lose your Medicaid Eligibility ................................................. Page 18

If you have Medicare ...................................................................... Page 18

If your child is having a baby .......................................................... Page 18

Section 7: Enrollment in Our Plan ......................................................... Page 18

Open Enrollment ............................................................................. Page 18

Enrollment in the SMMC Long-Term Care Program ....................... Page 19

Area Agencies on Aging ................................................................. Page 20

Section 8: Leaving Our Plan (Disenrollment) ....................................... Page 21

Removal from Our Plan (Involuntary Disenrollment) ...................... Page 22

Section 9: Managing Your Care ............................................................. Page 22

Changing Case Managers .............................................................. Page 23

Important Things to Tell Your Case Manager ................................. Page 23

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 10: Accessing Services ............................................................ Page 23

Providers in Our Plan ..................................................................... Page 23

Providers Not in Our Plan ............................................................... Page 24

Dental Services .............................................................................. Page 24

What Do I Have To Pay For? .......................................................... Page 25

Services for Children ...................................................................... Page 25

Moral or Religious Objections ......................................................... Page 26

Important Facts to Remember ........................................................ Page 26

Medical Consenter .......................................................................... Page 26

Role of Medical Consenter ............................................................. Page 26

Section 11: Helpful Information About Your Benefits .......................... Page 26

Choosing a Primary Care Provider (PCP) ...................................... Page 26

Choosing a PCP for Your Child ...................................................... Page 27

Specialist Care and Referrals ......................................................... Page 27

Second Opinions ............................................................................ Page 28

Urgent Care .................................................................................... Page 28

Hospital Care .................................................................................. Page 28

Emergency Care ............................................................................. Page 28

Provider Standards for PCP and Specialist

Appointment Scheduling ................................................................. Page 30

Filling Prescriptions ........................................................................ Page 31

Specialty Pharmacy Information .................................................... Page 31

Behavioral Health Services ............................................................ Page 31

Member Reward Programs ............................................................ Page 33

Disease Management Programs .................................................... Page 35

Advance Directives ......................................................................... Page 36

Quality Enhancement Programs ..................................................... Page 37

Well Child Visits .............................................................................. Page 37

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Domestic Violence .......................................................................... Page 38

Pregnancy Prevention .................................................................... Page 38

Case Management ......................................................................... Page 38

Caregiver Training .......................................................................... Page 39

Enhancing Transitional Services Program ...................................... Page 39

Promoting Adoption Success Program ........................................... Page 40

Healthy Teen Pregnancy Program ................................................. Page 40

Healthy Start Partnerships .............................................................. Page 40

Nutritional Assessment and Counseling ......................................... Page 40

Behavioral Health ........................................................................... Page 40

Child Welfare Advisory Committee ................................................. Page 41

Section 12: Your Plan Benefits:

Managed Medical Assistance Services ................................................. Page 41

Your Plan Benefits: Expanded Benefits .......................................... Page 56

Section 13: Long-Term Care Program Helpful Information ................. Page 58

Starting Services ............................................................................ Page 58

Developing a Plan of Care .............................................................. Page 59

Updating Your Plan of Care ............................................................ Page 59

Your Back-Up Plan ......................................................................... Page 60

Section 14: Your Plan Benefits: Long-Term Care Services ................. Page 61

Long-Term Care Participant Direction Option ................................. Page 67

Your Plan Benefits: LTC Expanded Benefits .................................. Page 68

Section 15: Member Satisfaction ........................................................... Page 69

Complaints, Grievances and Plan Appeals .................................... Page 69

Fast Plan Appeal ............................................................................ Page 71

Medicaid Fair Hearings (for Medicaid Members) ............................ Page 71

Review by the State (for MediKids Members)................................. Page 71

Continuation of Benefits for Medicaid Members ............................. Page 72

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 16: Your Child’s Member Rights .............................................. Page 72

LTC Members have the right to: ..................................................... Page 73

Section 17: Your Member Responsibilities ........................................... Page 74

LTC Members have the responsibility to: ....................................... Page 74

Section 18: Other Important Information .............................................. Page 75

Patient Responsibility ..................................................................... Page 75

Emergency Disaster Plan ............................................................... Page 75

Fraud/Abuse/Overpayment in the Medicaid Program ..................... Page 75

Abuse/Neglect/Exploitation of People ............................................. Page 76

Advance Directives ......................................................................... Page 76

Getting More Information ................................................................ Page 77

Section 19: Additional Resources ......................................................... Page 78

Floridahealthfinder.gov ................................................................... Page 78

Elder Housing Unit .......................................................................... Page 78

MediKids Information ...................................................................... Page 78

Aging and Disability Resource Center ............................................ Page 78

Independent Consumer Support Program ...................................... Page 79

Section 20: Forms ................................................................................... Page 79

Appointment of a Designated Representative ................................ Page 80

Authorization to Use and Disclose Health Information .................... Page 81

Revocation of Authorization to Use

and/or Disclose Health Information ................................................. Page 84

Consent for Release of Medical Records ....................................... Page 85

Member Notification of Pregnancy .................................................. Page 87

Specialty Pharmacy Change Request Form ................................... Page 89

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Welcome to Sunshine Health’s Statewide Child Welfare Specialty Plan

Sunshine Health has a contract with the Florida Agency for Health Care Administration

(Agency) to provide health care services to people with Medicaid. This is called the

Statewide Medicaid Managed Care (SMMC) Program. Your child is enrolled in our

SMMC plan. This means that we will offer your child Medicaid services. We work with a

group of health care providers to help meet your child’s needs.

There are many types of Medicaid services that your child can receive in the SMMC

program. Your child can receive medical services, like doctor visits, labs and emergency

care, from a Managed Medical Assistance (MMA) plan. If you are an elder or adult with

disabilities, you can receive nursing facility and home and community-based services in a

Long-Term Care (LTC) plan. If you have a certain health condition, like AIDS, you can

receive care that is designed to meet your needs in a Specialty plan.

If your child is enrolled in the Florida KidCare MediKids program, most of the information in

this handbook applies to you. We will let you know if something does not apply.

This handbook will be your guide for all health care services available to your child. You can

ask us any questions, or get help making appointments. If you need to speak with us, just

call us at 1-855-463-4100.

Questi

ons? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 1: Your Plan Identification Card (ID card)

You should have received your child’s ID card in the mail. Call us if you have not received

your child’s card or if the information on your child’s card is wrong. Each member of your

family in our Plan should have their own ID card.

Carry your child’s ID card at all times and show it each time you go to a health care

appointment. Never give your child’s ID card to anyone else to use. If your child’s card is

lost or stolen, call us so we can give you a new card.

Your child’s ID card will look like this:

(Front)

(Back)

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 2: Your Privacy

Your privacy is important to us. You have rights when it comes to protecting your child’s

health information, such as your child’s name, Plan identification number, race, ethnicity and

other things that identify your child. We will not share any health information about your child

that is not allowed by law.

If you have any questions, call Member Services. Our Sunshine Health Privacy Practices

describe how medical information about your child may be used and disclosed and how you

can get access to this information. Please review this carefully.

For help to translate or understand this information, please call 1-855-463-4100. Hearing

impaired TTY 1-800-955-8770.

Si necesita ayuda para traducir o entender este texto, por favor llame al telefono.

1-855-463-4100. (TTY 1-800-955-8770).

Interpreter services are provided free of charge to you.

Covered Sunshine Duties

At Sunshine Health, your privacy is important to us. We will do all we can to protect your

child’s health records. By law, we must protect these health records.

Our Privacy Practice policy tells you how we use your child’s health records. It describes

when we can share your child’s records with others. It explains your rights about the use of

your child’s health records. It also tells you how to use those rights and who can see your

child’s health records. Our Privacy Practice policy does not apply to health records that do

not identify your child. If one of the below reasons does not apply, we must get your written

consent.

Sunshine Health can change our Privacy Practices. Any changes in our Privacy Practices

will apply to all the health records we keep. If we make changes, we will send you a notice.

Please note: You will also receive a Privacy Practice Notice from Medicaid outlining their

rules for your child’s health records. Other health plans and health care providers may have

other rules when using or sharing your child’s health records. We ask that you obtain a copy

of their Privacy Practice Notices and read them carefully.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

How We Use or Share Your Health Records

Below is a list of how we may use or share your child’s health records without your consent:

• Treatment. We may use or share your child’s health records with doctors or other

health care providers providing medical care to your child and to help manage your

child’s care. For example, if your child is in the hospital we may give the hospital your

child’s records sent to us by your child’s doctor.

• Payment. We may use and disclose your child’s PHI to make benefit payments for

the health care services provided to your child. We may release your child’s PHI to

another health plan, to a health care provider, or other entity subject to the federal

Privacy Rules for their payment purposes.

• Health Care Operations. We may use and share your child’s health records to

perform our health care operations. To help resolve any appeals or grievances filed

by you or a health care provider with Sunshine Health or the State of Florida. To help

assist others who help us provide your child’s health services. We will not share your

child’s records with these groups unless they agree to protect your records.

• Appointment Reminders/Treatment Alternatives. We may use and release your

child’s health records to remind you of dates and times for treatment and medical

care with us. We may also use or release it to give you information about treatment

options. We may also use or release it for other health related benefits and services.

For instance, information on how to stop smoking or lose weight.

• As Required by Law. We may use or share your child’s health records without your

consent if any law office requires them. The request will be met when the request

complies with the law. If there are any legal conflicts, we will comply with the law that

better protects you and your child’s health records.

• Public Health Activities. We may release your child’s health records to a public

health authority to prevent or control disease, injury, or disability. We may release

your child’s health records to the Food and Drug Administration (FDA). We can do

this to ensure the quality, safety or effectiveness of products or services under the

control of the FDA.

• Victims of Abuse and Neglect. We may release your child’s health records to a

local, state, or federal government authority. This includes social services or a

protective services agency authorized by law to have these reports. We will do this if

we have reason to believe there is a case of abuse, neglect or domestic violence.

• Judicial and Administrative Proceedings. We may release your child’s health

records in judicial and administrative proceedings, as well as in response to an order

of a court, administrative tribunal, or in response to a subpoena, summons, warrant,

discovery request, or similar legal request.

• Law Enforcement. We may release your child’s health records to law enforcement

when required. For instance, a court order, court-order warrant, subpoena or

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

summons issued by a judicial officer, or a grand jury subpoena. We may also release

your child’s health records to find or locate a suspect, fugitive, or missing person.

• Coroners, Medical Examiners and Funeral Directors. We may release your child’s

health records to a coroner or medical examiner. This may be needed, for example,

to decide a cause of death. We may also release your child’s health records to

funeral directors, as needed, to carry out their duties.

• Organ, Eye and Tissue Donation. We may release your child’s health records to

organ procurement organizations or entities engaged in the procurement, banking or

transplantation of cadaveric organs, eyes, or tissues.

• Threats to Health and Safety. We may use or release your child’s health records if

we believe, in good faith, that it is needed to prevent or lessen a serious or looming

threat. This includes threats to the health or safety of a person or the public.

• Specialized Government Functions. If your child is a member of U.S. Armed

Forces, we may release your child’s health records as required by military command

authorities. We may also release your child’s health records to:

• authorized federal officials for national security

• aid in intelligence activities

• the Department of State for medical suitability determinations

• protective services of the President or other authorized persons

• Workers’ Compensation. We may release your child’s health records to comply

with laws relating to workers’ compensation or other like programs, established by

law. These are programs that provide benefits for work-related injuries or illness

without regard to fault.

• Emergency Situations. We may release your child’s health records in an

emergency situation, or if you are unable to respond or are not present. This includes

to a family member, close personal friend, authorized disaster relief agency, or any

other person you told us about. We will use professional judgment and experience to

decide if the release is in your child’s best interests. If it is in your child’s best

interest, we will release only health records that are directly relevant to the person’s

involvement in your child’s care.

• Inmates. If your child is an inmate of a correctional institution or under the custody of

a law enforcement official, we may release your child’s PHI to the correctional

institution or law enforcement official where such information is necessary for the

institution to provide your child with health care, to protect your child’s health or safety,

or the health or safety of others, or for the safety and security of the correctional

institution.

• Research. In some cases, we may release your child’s health records to researchers

when their clinical research study has been approved. They must have safeguards in

place to ensure the privacy and protection of your child’s health records.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Uses and Releases of Your Health Records That Require Your Written Consent

We are required to get your written consent to use or release your child’s health records,

with few exceptions, for the reasons below:

• Sale of Health Records. We will request your written consent before we make any

release of your child’s health records for which payment may be made to us.

• Marketing. We will request your written consent to use or release your child’s health

records for marketing purposes with limited exceptions. For instance, we don’t need

your consent when we have a face-to-face event with you or when we give

promotional gifts of modest value.

• Psychotherapy Notes. We will request your written consent to use or share any of

your child’s psychotherapy notes that we may have on file with limited exception. For

instance, for certain treatment, payment or health care operation functions.

All other uses and releases of your child’s health records not described in this notice will be

made only with your written consent. You may cancel consent at any time. The request to

cancel consent must be in writing. Your request to cancel consent will take effect as soon

as you request it, except in two cases. The first case is when we have already taken actions

based on past consent. The second case is before we received your written request to stop.

Member Rights

Below are your rights with regard to your child’s health records. If you would like to use any

of the rights, please contact us using the information provided at the end of this notice.

• Right to Revoke. You may revoke your consent to have your child’s PHI released at

any time. It must be in writing. It must be signed by you or on your behalf. It must be

sent to the address at the end of this section. You may submit your letter either by

mail or in person. It will be effective when we actually received it. The revoked

consent will not be effective if we or others have already acted on the signed form.

• Request Restrictions. You have the right to ask for limits on the use and release of

your child’s PHI for treatment, payment or health care operations as well as releases

to persons involved in your care or payment of your care. This includes family

members or close friends. Your request should be detailed and exact. It should also

say to whom the limit applies. We are not required to agree to this request. If we

agree, we will comply with your limit request. We will not comply if the information is

needed to provide your child with emergency treatment. However, we will limit the

use or release of health records for payment or health care operations to a health

plan when you have paid for the service or item out of pocket in full.

• Right to Request Confidential Communications. You have the right to ask that we

communicate with you about your child’s health records in other ways or

locations. This right only applies if the information could harm your child if it is not

communicated in other ways or place. You do not have to explain the reason for your

request. You must state how your child could be harmed if the change is not

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

made. We must work with your request if it is reasonable and states the other way or

place where your child’s health records should be sent.

• Right to Access and Receive a Copy of your Health Records. You have the right,

with certain limits, to look at or get copies of your child’s health records contained in a

record set. You may ask that we give copies in a format other than photocopies. If it

is possible, we will use the format of your choice. You must ask in writing to get

access to your child’s health records. If we deny your request, we will provide you a

written reason. We will tell you if the reasons for the denial can be reviewed. We will

also let you know how to ask for a review or if the denial cannot be reviewed.

• Right to Change your Health Records. You have the right to ask us to make

changes to correct your child’s health records. These changes are known as

amendments. Any request for an amendment must be in writing. You need to give a

reason for your change request. We will contact you in writing no later than 60 days

after we get your request. If we need more time, we may take up to another 30 days.

We will let you know of any delays and the date when we will get back to you.

If we make the changes, we will let you know they were made. We will also give your

changes to others who we know have your child’s health records and to other

persons you name. If we choose not to make your changes, we will let you know why

in writing. You have a right to dispute the denied change request in writing.

• Right to Receive an Accounting of Disclosures. You have the right to receive a

list of instances within the last six years in which we or our business associates

released your child’s PHI. This does not apply to the release for purposes of

treatment, payment, health care operations, or disclosures you authorized and

certain other events. If you request this accounting more than once in a 12-month

period, we may charge you a reasonable, cost-based fee for responding to these

additional requests. We will provide you with more details on our fees at the time of

your request.

• Right to File a Complaint. If you feel your child’s privacy rights have been violated,

or that we have violated our own privacy practices, you can file a complaint with

us. You can also do this by phone. Use the contact information at the end of this

section. You will not be retaliated against for filing a complaint.

You can also file a complaint with the Secretary of the U.S. Department of Health and

Human Services Office for Civil Rights by sending a letter to 200 Independence

Avenue SW, Washington, D.C. 20201, or calling 1-800-368-1019 (TTY 1-866-788-

4989), or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

WE WILL NOT TAKE ANY ACTION AGAINST YOU FOR FILING A COMPLAINT.

• Right to Receive a Copy of this Privacy Practice. You may ask for a copy at any

time. Use the contact information listed below. If you get our Privacy Practice on our

website or by email, you can request a paper copy of the notice.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Contact Information

If you have any questions about our privacy practices related to your child’s health records

or how to use your rights, you can contact us in writing. You can also contact us by phone.

Use the contact information listed below.

Sunshine Health

Attn: Privacy Official

P.O. Box 459089

Fort Lauderdale, FL 33345-9089

TEL: 1-866-796-0530

TTY: 1-800-955-8770

Section 3: Getting Help from Our Member Services

Our Member Services Department can answer all of your questions. We can help you

choose or change your child’s Primary Care Provider (PCP for short), find out if a service is

covered, get referrals, find a provider, replace a lost ID card, report the birth of a baby and

explain any changes that might affect your child’s benefits.

Contacting Member Services

You may call us at 1-855-463-4100, or our

TTY line at 1-800-955-8770, Monday to

Friday, 8 a.m. to 8 p.m., but not on State

holidays (like Christmas Day and

Thanksgiving Day). When you call, make

sure you have your child’s identification

card (ID card) with you so we can help you.

(If you lose your child’s ID card, or if it is

stolen, call Member Services.)

Contacting Member Services After Hours

If you call when we are closed, please leave

a message. We will call you back the next

business day. If you have an urgent

question, call our 24-hour Nurse Advice

Line at 1-855-463-4100. Our nurses are

available to help you 24 hours a day, seven

days a week.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 4: Do You Need Help Communicating?

If you do not speak English, we can help. We have people who help us talk to you in your

language. We provide this help for free.

For people with disabilities: If you or your child uses a wheelchair, or are blind, or have

trouble hearing or understanding, call us if you need extra help. We can tell you if a

provider’s office is wheelchair accessible or has devices for communication. Also, we have

services like:

• Telecommunications Relay Service. This helps people who have trouble hearing or

talking to make phone calls. Call 711 and give them our Member Services phone

number. It is 1-855-463-4100. They will connect you to us.

• Information and materials in large print, audio (sound); and braille.

• Help in making or getting to appointments.

• Names and addresses of providers who specialize in your disability.

All of these services are provided free to you.

Section 5: When Your Information Changes

If any of your child’s personal information changes, let us know as soon as possible. You

can do so by calling Member Services. We need to be able to reach you about your child’s

health care needs.

The Department of Children and Families (DCF) needs to know when your child’s name,

address, county, or telephone number changes, as well. Call DCF toll-free at 1-866-762-

2237 (TTY 1-800-955-8771) Monday through Friday from 8 a.m. to 5:30 p.m. You can also

go online and make the changes in your Automated Community Connection to Economic

Self Sufficiency (ACCESS) account at https://dcf-access.dcf.state.fl.us/access/index.do. You

may also contact the Social Security Administration (SSA) to report changes. Call SSA toll

free at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday from 7 a.m. to 7 p.m.

You may also contact your local Social Security office or go online and make changes in

your my Social Security account at https://secure.ssa.gov/RIL/SiView.do.

Section 6: Your Medicaid Eligibility

In order for you to go to your child’s health care appointments and for Sunshine Health to

pay for your services, your child has to be covered by Medicaid and enrolled in our plan.

This is called having Medicaid eligibility. DCF decides if someone qualifies for Medicaid.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Sometimes things in your life might change, and these changes can affect whether or not

your child can still have Medicaid. It is very important to make sure that your child has

Medicaid before you go to any appointments. Just because you have a Plan ID card does

not mean that your child still has Medicaid. Do not worry! If you think your child’s Medicaid

has changed or if you have any questions about your child’s Medicaid, call Member

Services and we can help you check on it.

If you lose your Medicaid Eligibility

If your child loses his or her Medicaid and gets it back within 180 days, your child will be

enrolled back into our plan.

If you have Medicare

If your child has Medicare, continue to use your child’s Medicare ID card when he or she

needs medical services (like going to the doctor or the hospital), but also give the provider

your child’s Medicaid Plan ID card, too.

If your child is having a baby

If your child has a baby, he or she will be covered by us on the date of birth. Call Member

Services to let us know that your child’s baby has arrived and we will help make sure your

child’s baby is covered and has Medicaid right away.

It is helpful if you let us know that your child is pregnant before your child’s baby is born to

make sure that your child’s baby has Medicaid. Call DCF toll-free at 1-866-762-2237 while

your child is pregnant. If you need help talking to DCF, call us. DCF will make sure your

child’s baby has Medicaid from the day he or she is born. They will give you a Medicaid

number for your child’s baby. Let us know the baby’s Medicaid number when you get it.

Section 7: Enrollment in Our Plan

When your child first joins our plan, you have 120 days to try our plan. If you do not like it for

any reason, you can enroll in another SMMC plan in this region. Once those 120 days are

over, your child is enrolled in our plan for the rest of the year. This is called being locked-in

to a plan. Every year you have Medicaid and are in the SMMC program, you will have an

open enrollment period.

Open Enrollment

Open enrollment is a period that starts 60 days before the end of your year in our plan. The

State’s Enrollment Broker will send you a letter letting you know that you can change plans

if you want. This is called your Open Enrollment period. You do not have to change plans.

If you leave our plan and enroll in a new one, you will start with your new plan at the end of

your year in our plan. Once you are enrolled in the new plan, you will have another 60 days

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

to decide if you want to stay in that plan or change to a new one before you are locked-in for

the year. You can call the Enrollment Broker at 1-877-711-3662 (TTY 1-866-467-4970).

Enrollment in the SMMC Long-Term Care Program

The SMMC Long-Term Care (LTC) program provides nursing facility services and home and

community-based care to elders and adults (ages 18 years and older) with disabilities.

Home and community-based services help people stay in their homes, with services like

help with bathing, dressing and eating; help with chores; help with shopping; or supervision.

We pay for services that are provided at the nursing facility. If your child lives in a Medicaid

nursing facility full time, he or she is probably already in the LTC program. If you don’t know,

or don’t think your child is enrolled in the LTC program, call Member Services. We can help

you.

The LTC program also provides help for people living in their home. But space is limited for

these in-home services, so before your child can receive these services, you have to speak

to someone who will ask you questions about your child’s health. This is called a screening.

The Department of Elder Affairs’ Aging and Disability Resource Centers (ADRCs) complete

these screenings. Once the screening is complete, your child’s name will go on a wait list.

When your child gets to the top of the waiting list, the Department of Elder Affairs

Comprehensive Assessment and Review for Long-Term Care Services (CARES) program

will ask you to provide more information about your child to make sure your child meets

other medical criteria to receive services from the LTC program. Once your child is enrolled

in the LTC program, we will make sure your child continues to meet requirements for the

program each year.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

You can find the phone number for your local ADRC using the following map.

They can also help answer any other questions that you have about the LTC program.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 8: Leaving Our Plan (Disenrollment)

Leaving a plan is called disenrolling. If you want to leave our plan while you are locked-in,

you have to call the State’s Enrollment Broker. By law, people cannot leave or change plans

while they are locked-in except for very special reasons. The Enrollment Broker will talk to

you about why you want to leave the plan. The Enrollment Broker will also let you know if

the reason you stated allows you to change plans.

You can leave our plan at any time for the following reasons (also known as Good Cause

Disenrollment reasons

• Your child is getting care at this time from a provider that is not part of our plan but is

a part of another plan

• We do not cover a service for moral or religious reasons

• Your child is an American Indian or Alaskan Native

• Your child lives in and gets his or her Long-Term Care services from an assisted

living facility, adult family care home, or nursing facility provider that was in our

network but is no longer in our network

You can also leave our plan for the following reasons, if you have completed our grievance

and appeal process

• Your child received poor quality of care, and the Agency agrees with you after they

have looked at your child’s medical records

• You cannot get the services your child needs through our plan, but your child can get

the services he or she needs through another plan

• Your child’s services were delayed without a good reason

If you have any questions about whether you can change plans, call Member Services or

the State’s Enrollment Broker at 1-877-711-3662 (TTY 1-866-467-4970).

For the full list of Good Cause Disenrollment reasons, please see Florida Administrative

Rule 59G-8.600:https://www.flrules.org/gateway/RuleNo.asp?title=MANAGED

CARE&ID=59G-8.600

To learn how to ask for an appeal, please turn to Section 15, Member Satisfaction,

on Page 65.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Removal from Our Plan (Involuntary Disenrollment)

The Agency can remove your child from our plan (and sometimes the SMMC program

entirely) for certain reasons. This is called involuntary disenrollment. These reasons

include:

• Your child loses his or her Medicaid

• Your child moves outside of where we operate, or outside the State of Florida

• You knowingly use your child’s Plan ID card incorrectly or let someone else use your

child’s Plan ID card

• You fake or forge prescriptions

• You, your child or your child’s caregivers behave in a way that makes it hard for us to

provide your child with care

• Your child is in the LTC program and lives in an assisted living facility or adult family

care home that is not home-like and you will not move your child into a facility that is

home-like

If the Agency removes your child from our plan because you broke the law or for your

behavior, you cannot come back to the SMMC program.

Section 9: Managing Your Care

If your child has a medical condition or illness that requires extra support and coordination,

we may assign a case manager to work with you. Your case manager will help you get the

services your child needs. The case manager will work with your child’s other providers to

manage your child’s health care. If we provide you with a case manager and you do not

want one, call Member Services to let us know.

If your child is in the LTC program, we will assign you a case manager. Your child must

have a case manager if your child is in the LTC program. Your child’s case manager is your

go-to person and is responsible for coordinating your child’s care. This means that they

are the person who will help you figure out what LTC services your child needs and how to

get them.

If you have a problem with your child’s care, or something in your child’s life changes, let

your case manager know and they will help you decide if your child’s services need to

change to better support your child.

This is for Long-Term Care program members only. If you have questions about your

facility’s compliance with this federal requirement, please call Member Services or your case

manager.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Changing Case Managers

If you want to choose a different case manager, call Member Services. There may be times

when we will have to change your case manager. If we need to do this, we will send a letter

to let you know.

Important Things to Tell Your Case Manager

If something changes in your child’s life or you don’t like a service or provider, let your case

manager know. You should tell your case manager if:

• You don’t like a service

• You have concerns about a service provider

• Your child’s services aren’t right

• Your child gets new health insurance

• Your child goes to the hospital or emergency room

• Your child’s caregiver can’t help you anymore

• Your child’s living situation changes

• Your child’s name, telephone number, address, or county changes

Request to Put Your Services on Hold

If something changes in your life and you need to stop your service(s) for a while, let your

case manager know. Your case manager will ask you to fill out and sign a form to put your

service(s) on hold.

Section 10: Accessing Services

Before your child gets a service or goes to a health care appointment, we have to make

sure that your child needs the service and that it is medically right for your child. This is

called prior authorization. To do this, we look at your child’s medical history and

information from your child’s doctor or other health care providers. Then we will decide if

that service can help your child. We use rules from the Agency to make these decisions.

Providers in Our Plan

For the most part, your child must use doctors, hospitals and other health care providers

that are in our provider network. Our provider network is the group of doctors, therapists,

hospitals, facilities and other health care providers that we work with. You can choose from

any provider in our provider network. This is called your freedom of choice. If your child

uses a health care provider that is not in our network, you may have to pay for that

appointment or service.

You will find a list of providers that are in our network in our provider directory. If you want a

copy of the provider directory, call 1-855-463-4100 to get a copy, or visit our website at

https://www.sunshinehealth.com.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

If your child is in the LTC program, your child’s case manager is the person who will help

you choose a service provider for each of your child’s services. Once you choose a service

provider, they will contact them to begin your child’s services. This is how services are

approved in the LTC program. Your case manager will work with you, your child, your

family, your child’s caregivers, your child’s doctors and other providers to make sure that

your child’s LTC services work with your child’s medical care and other parts of your child’s

life.

Providers Not in Our Plan

There are some services that your child can get from providers who are not in our provider

network. These services are:

• Family planning services and supplies

• Women’s preventive health services, such as breast exams, screenings for cervical

cancer and prenatal care

• Treatment of sexually transmitted diseases

• Emergency care

If we cannot find a provider in our provider network for these services, we will help you find

another provider that is not in our network. Remember to check with us first before your

child uses a provider that is not in our provider network. If you have questions, call Member

Services.

Dental Services

Your child’s dental plan will cover most of your child’s dental services, but some dental

services may be covered by Sunshine Health. The table below will help you to decide which

plan pays for a service.

Type of Dental Service(s)

Dental Plan Covers

Medical Plan Covers

Dental Services

Covered when you see

your child’s dentist or

dental hygienist

Covered when you see your

child’s doctor or nurse

Scheduled dental services in a

hospital or surgery center

Covered for dental

services by your

child’s dentist

Covered for doctors, nurses,

hospitals and surgery

centers

Hospital visit for a dental

problem

Not covered

Covered

Prescription drugs for your child’s

dental visit or problem

Not covered

Covered

Transportation to your child’s

dental service or appointment

Not covered

Covered

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

What Do I Have To Pay For?

You may have to pay for appointments or services that are not covered. A covered service

is a service that we have to provide in the Medicaid program. All of the services listed in this

handbook are covered services. Remember, just because a service is covered, does not

mean that your child will need it. You may have to pay for services if we did not approve it

first.

If you get a bill from a provider, call Member Services. Do not pay the bill until you have

spoken to us. We will help you.

Services for Children

We must provide all medically necessary services for our members who are ages 0 – 20

years old. This is the law. This is true even if we do not cover a service or the service has a

limit. As long as your child’s services are medically necessary, services have:

• No dollar limits; or

• No time limits, like hourly or daily limits

Your provider may need to ask us for approval before giving your child the service. Call

Member Services if you want to know how to ask for these services.

Services Covered by the Medicaid Fee-for-Service Delivery System, Not Covered

Through Sunshine Health

The Medicaid fee-for-service program is responsible for covering the following services,

instead of Sunshine Health covering these services:

• Behavior Analysis (BA)

• County Health Department (CHD) Certified Match Program

• Developmental Disabilities Individual Budgeting (iBudget) Home and Community-

Based Services Waiver

• Familial Dysautonomia (FD) Home and Community-Based Services Waiver

• Hemophilia Factor-related Drugs

• Intermediate Care Facility Services for Individuals with Intellectual Disabilities

(ICF/IID)

• Medicaid Certified School Match (MCSM) Program

• Model Home and Community-Based Services Waiver

• Newborn Hearing Services

• Prescribed Pediatric Extended Care

• Substance Abuse County Match Program

This Agency webpage provides details about each of the services listed above and how to

access these services:

Also known as “Early and Periodic Screening, Diagnosis and Treatment” or “EPSDT” requirements.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

http://ahca.myflorida.com/Medicaid/Policy_and_Quality/Policy/Covered_Services_HCBS_W

aivers.shtml.

Moral or Religious Objections

If we do not cover a service because of a religious or moral reason, we will tell you that the

service is not covered. In these cases, you must call the State’s Enrollment Broker at 1-877-

711-3662 (TTY 1-866-467-4970). The Enrollment Broker will help you find a provider for

these services.

Important Facts to Remember

If you have questions about who can provide consent for medical services, please contact

your assigned Community Based Care (CBC) Lead Agency. If you need help getting in

touch with them, call us at 1-855-463-4100.

Sunshine Health, by law, will keep your child’s health records private. Your discussions with

doctors or other health care providers are also private. If you are the Medical Consenter or

Legal Guardian, you have the right to say yes or no to requests for your child’s records by

someone other than those handling your child’s health care, unless a court orders release of

those records.

Medical Consenter

A Medical Consenter is the person whom a court has said can consent to medical care for a

child in the custody of the State. The Medical Consenter may be the child’s foster parent, a

CBC staff member, or a relative of the child. The child’s parent may also be a Medical

Consenter if their rights have not been terminated.

Role of Medical Consenter

The Medical Consenter agrees to a child’s medical care. They also take part in the child’s

medical appointments. Medical care means “health care and related services.” This may

include medical, behavioral, dental, or eye care. This does not apply to emergency services.

Contact 911, or go to the nearest hospital or emergency facility, if you think your child needs

emergency care.

Section 11: Helpful Information About Your Benefits

Choosing a Primary Care Provider (PCP)

If your child has Medicare, please contact the number on your child’s Medicare ID card for

information about your child’s PCP. You do not have to change your Medicare PCP to get

medical services. You can keep your same Medicare PCP. If you do not have a Medicare

PCP, we can help you find one.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

If you have Medicaid or MediKids but you do not have Medicare, one of the first things you

will need to do when your child enrolls in our plan is choose a PCP. This can be a doctor,

nurse practitioner, or a physician assistant. Your child will see his or her PCP for regular

check-ups, shots (immunizations), or when your child is sick. Your child’s PCP will also help

your child get care from other providers or specialists. This is called a referral. You can

choose your child’s PCP by calling Member Services.

You can choose a different PCP for each family member or you can choose one PCP for the

entire family. If you do not choose a PCP, we will assign a PCP for your child.

You can change your child’s PCP at any time. To change your child’s PCP, call Member

Services.

Choosing a PCP for Your Child

If your child is having a baby, you can pick a PCP for the baby

before it is born. We can help you with this by calling Member

Services. If you do not pick a doctor by the time your child’s

baby is born, we will pick one for you. If you want to change your

child’s baby’s doctor, call us.

It is important that you select a PCP for your child’s baby to

make sure they get their well child visits each year. Well child visits are for children 0 – 20

years old. These visits are regular check-ups that help you know what is going on with the

child and how they are growing. The child may also receive shots (immunizations) at these

visits. These visits can help find problems and keep your child healthy.

You can take the child to a pediatrician, family practice provider, or other health care

provider.

You do not need a referral for well child visits.

There is no charge for well child visits.

Specialist Care and Referrals

Sometimes, your child may need to see a provider other than a PCP for medical problems

like special conditions, injuries, or illnesses. Talk to your child’s PCP first. Your child’s PCP

will refer you to a specialist. A specialist is a provider who works in one health care area.

If your child has a case manager, make sure you tell your child’s case manager about your

child’s referrals. The case manager will work with the specialist to get your child care.

For more information about the screenings and assessments that are recommended for

children, please refer to the “Recommendations for Preventative Pediatric Health Care –

Periodicity Schedule” at www.aap.org.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Second Opinions

You have the right to get a second opinion about your child’s care. This means talking to a

different provider to see what they have to say about your child’s care. The second provider

will give you their point of view. This may help you decide if certain services or treatments

are best for your child. There is no cost to you to get a second opinion.

Your child’s PCP, case manager or Member Services can help find a provider to give you a

second opinion. You can pick any of our providers. If you are unable to find a provider with

us, we will help you find a provider that is not in our provider network. If your child needs to

see a provider that is not in our provider network for the second opinion, we must approve it

before your child sees them.

Urgent Care

Urgent Care is not Emergency Care. Urgent Care is needed when your child has an injury

or illness that must be treated within 48 hours. Your child’s health or life is not usually in

danger, but your child cannot wait to see his or her PCP or it is after your child’s PCP’s

office has closed.

If your child needs Urgent Care after office hours and you cannot reach your child’s PCP,

call our 24-hour Nurse Advice Line at 1-855-463-4100. You will be connected to a nurse.

Have your child’s Sunshine Health ID card number handy. The nurse may help you over the

phone or direct you to other care. You may have to give the nurse your phone number.

During normal office hours, the nurse will assist you in contacting your child’s PCP.

You may also find the closest Urgent Care center to you by calling Member Services at

1-855-463-4100 or visiting our website at SunshineHealth.com and clicking “Find a

Provider.”

Hospital Care

If your child needs to go to the hospital for an appointment, surgery or overnight stay, your

child’s PCP will set it up. We must approve services in the hospital before your child goes,

except for emergencies. We will not pay for hospital services unless we approve them

ahead of time or it is an emergency.

If your child has a case manager, they will work with you and your child’s provider to put

services in place when your child goes home from the hospital.

Emergency Care

Your child has a medical emergency when your child is so sick or hurt that your child’s life

or health is in danger if your child does not get medical help right away. Some examples

are:

• Broken bones

• Bleeding that will not stop

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

• Your child is pregnant, in labor and/or bleeding

• Trouble breathing

• Suddenly unable to see, move, or talk

Emergency services are those services that your child gets when your child is very ill or

injured. These services try to keep your child alive or to keep your child from getting worse.

They are usually delivered in an emergency room.

If your child’s condition is severe, call 911 or go to the closest emergency facility

right away. Your child can go to any hospital or emergency facility. If you are not sure

if it is an emergency, call your child’s PCP. Your child’s PCP will tell you what to do.

The hospital or facility does not need to be part of our provider network or in our service

area. You also do not need to get approval ahead of time to get emergency care or for the

services that your child receives in an emergency room to treat your child’s condition.

If your child has an emergency when you are away from home, get the medical care your

child needs. Be sure to call Member Services when you are able and let us know.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Provider Standards for PCP and Specialist Appointment Scheduling

PCP Appointment Type

Access Standard

Urgent Care

Within 48 hours for service that

does not require prior authorization

and within 96 hours for services

that do require prior authorization

Regular and Routine Well Exam

Within 30 days

After Hours Care

PCPs must offer after hours

appointments

Specialist Appointment Type

Access Standard

New Patient Appointment

Within 60 days of request with

appropriate referral

Routine Prenatal Exams

Within four weeks until week 32,

every two weeks until week 36 and

every week thereafter until delivery

Oncology: New Patient

Appointment

Within 30 days of request

Follow Up After Physical Health

Admission

Within seven days of discharge

from the hospital

Behavioral Health

Appointment Type

Access Standard

Non-life Threatening Emergency

Within six hours

Urgent Access

Within 48 hours

Initial Visit for Routine Care

Within 10 business days

Follow Up for Routine Care

Within 30 calendar days

Follow Up After Behavioral

Health Hospital Admission

Within seven calendar days

After Hours

Your BH provider must have a call

service that is answered by a live

person

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Filling Prescriptions

We cover a full range of prescription medications. We have a list of drugs that we cover.

This list is called our Formulary. You can find this list on our website at

https://www.sunshinehealth.com/members/medicaid/benefits-services/pharmacy.html or by

calling Member Services.

We cover brand name and generic drugs. Generic drugs have the same ingredients as

brand name drugs, but they are often cheaper than brand name drugs. They work the

same. Sometimes, we may need to approve using a brand name drug before your child’s

prescription is filled.

We have pharmacies in our provider network. You can fill your child’s prescription at any

pharmacy that is in our provider network. Make sure to bring your child’s Plan ID card with

you to the pharmacy.

The list of covered drugs may change from time to time, but we will let you know if anything

changes.

Specialty Pharmacy Information

Some drugs are not available at a local pharmacy. These drugs are supplied by a specialty

pharmacy provider. These drugs may need prior approval before your prescription can be

filled. The pharmacy will tell your child’s doctor if the drugs have to be supplied by a

specialty pharmacy and if you need a prior approval.

Sunshine Health partners with AcariaHealth/Envolve Pharmacy Solution, Inc. to provide

specialty drugs. These are drugs that treat complex conditions. They require extra support

to make sure they are used correctly. You will be offered the option to select a different

specialty pharmacy by mail, after your initial specialty medication is filled. If you want a

different specialty pharmacy, complete the Specialty Pharmacy Change Request Form

provided and we will review and let you know if it is approved.

If you have questions about any of the pharmacy services or need help with this form, call

Member Services at 1-844-463-4100.

Behavioral Health Services

There are times when you may need to speak to a therapist or counselor, for example, if

your child is having any of the following feelings or problems:

• Always feeling sad

• Not wanting to do the things that your child used to enjoy

• Feeling worthless

• Having trouble sleeping

• Not feeling like eating

• Alcohol or drug abuse

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

We cover many different types of behavioral health services that can help with issues you

child may be facing. You can call a behavioral health provider for an appointment. You can

get help finding a behavioral health provider by:

• Calling Member Services at 1-855-463-4100

• Looking at our provider directory

• Going to our website at SunshineHealth.com.

Someone is there to help you 24 hours a day, seven days a week.

You do not need a referral from your child’s PCP for behavioral health services.

If your child is thinking about hurting himself or herself or someone else, call 911.

Your child can also go to the nearest emergency room or crisis stabilization center, even if it

is out of our service area. Once your child is in a safe place, call your child’s PCP if you can.

Follow up with your child’s provider within 24-48 hours. If your child gets emergency care

outside of the service area, we will make plans to transfer your child to a hospital or provider

that is in our plan’s network once your child is stable.

Sunshine Health can help your child in many ways. Together, we can help your child get

treatment. Children in the child welfare system have a history of being abused, abandoned,

or neglected and have often been exposed to trauma. There may be a need for the child to

receive behavioral health therapy or other supports to deal with the trauma he or she has

experienced. Sunshine Health contracts with multiple providers across the state who are

trained to work with children who have been traumatized, as well as those who have been

adopted.

This is how we can help:

• We can help you with referrals to behavioral health providers in your community,

including various community support groups.

• Sunshine Health Case Managers and Care Coordinators are available to help with

accessing services and finding the right provider to address your child’s behavioral

health needs.

• If you aren’t sure what to do, Sunshine Health has a 24-hour help line where you can

discuss your current concerns and get immediate guidance on how to manage the

situation. Sunshine Health’s help line is available 24 hours a day, at no cost to you

• Sunshine Health works closely with the Child Welfare Community Based Care lead

agencies (CBCs), Managing Entities and Adoption Specialists/Support agencies

throughout the state. We can also connect you to those resources for needs that are

not a Medicaid covered benefit.

• Most mental health and substance abuse services do not need a referral from your

child’s PCP. Providers in the community know how to contact us for a prior

authorization once they have completed an assessment and determined which

services would best meet the needs of your child and family.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

• For Statewide Inpatient Psychiatric Program (SIPP) services and Specialized

Therapeutic Group Care, a Multidisciplinary Treatment Team (MDT) or a Child

Specific Staffing (CSS) must occur. For children in the foster care system, a

suitability assessment must occur. For children who have been adopted, a psychiatric

evaluation must be completed. Sunshine Health staff can help you understand what

is needed and connect you to the right agency.

• You can call Sunshine Health toll-free at 1-855-463-4100.

Member Reward Programs

We offer programs to help keep your child healthy and to help your child live a healthier life

(like losing weight or quitting smoking). We call these healthy behavior programs. Your

child can earn rewards while participating in these programs. Our plan offers the following

programs:

Reward

Value

Limitations

Well Child Visits in First

15 Months

$50

• Ages birth up to 15 months.

• All six visits must be completed.

• Visit must be with a PCP.

Preventive Well Child

PCP Visits

$10

• Ages 2 to 20.

• Only one reward for this service per

calendar year.

Diabetic Screenings

• HbA1c test

• Nephropathy test

• Dilated eye exam

$40

• Members with diabetes.

• All three services must be completed within

same calendar year.

• Only one reward for this service per

calendar year.

Notification of

Pregnancy Form

$20 in first

trimester,

or $10 in

second

trimester.

• No age restriction.

Fill out our pregnancy form so we can

personalize the ways we help you. Three

easy ways to fill out our form:

• Mail in printed form.

• Call us.

• Go online. Log in to your Secure Member

Portal.

Postpartum Visit

$10

• No age restriction.

• Member does not have to be enrolled in

Start Smart for Your Baby.

• Postpartum visit must occur between 21 and

56 days after the delivery date.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Reward

Value

Limitations

Post Behavioral Health

Admission Follow Up Visit

$10

• No age restriction.

• Member must have been admitted to a

behavioral health inpatient acute care

facility.

• Visit post discharge must be with a

behavioral health provider.

• The visit post discharge must be within

seven calendar days after the date of the

discharge.

Substance Abuse Health

Coaching Sessions

Up to $30

• Ages 12 or older.

• Reward for up to three coaching sessions

with a case manager. The third session must

occur within three (3) months of the date of

the first session.

• Reward for a visit with a substance abuse

provider for any of the three (3) types of

outpatient visits below:

o Medication assisted treatment

o Intensive outpatient treatment

o Outpatient substance use provider

visit

• Reward is $5 after each completed session.

Tobacco Cessation Health

Coaching

Up to $20

• Ages16 and older.

• Member must sign and return the Program

Consent form.

• Member must state that they are willing to

stop using tobacco within 30 days.

• Complete up to four health coaching

sessions for tobacco cessation.

• The fourth session must be completed within

six months of the date of the first coaching

session.

• Reward is $5 after each completed session.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Reward

Value

Limitations

Weight Loss Health

Coaching

Up to $20

• Ages 13 and older.

• Member must sign and return the Program

Consent form.

• Member must state that they are willing to

take steps to lose weight within 30 days.

• Must complete four health coaching

sessions for weight loss.

• The fourth session must be completed within

six months of the date of the first coaching

session.

• Reward is $5 after each completed session.

Program Consent Form

Received for Agreement

to Participate in Tobacco

Cessation Health

Coaching or Weight Loss

Health Coaching

Programs

• Consent form must be signed and received

at Health Plan.

• Up to 2 program consents per calendar year.

One for Tobacco Cessation and one for

Weight Loss.

New Member Health Risk

Screening

$10

• A newly enrolled member in Sunshine

Health.

• Completion of a Health Risk Screening

within 60 days of enrollment.

• Only one reward.

How it works: Earning rewards is easy! When your child makes certain healthy choices,

reward dollars will automatically be put on your child’s rewards card. The rewards are added

approximately two weeks after we receive the claim from your child’s provider for the

healthy behavior your child has completed. If it’s your child’s first reward, a card will be

mailed to you.

Please remember that rewards cannot be transferred. If you leave our Plan for more than

180 days, your child may not receive his or her reward. If you have questions or are

interested in having your child join any of these programs, please call us at 1-855-463-4100

(TTY 1-800-955-8770).

Disease Management Programs

Not all members need case management. Sunshine Health has several programs to

improve the health of our members with chronic conditions. We know this means more than

just helping your child to see a doctor. It means helping you and your child understand and

manage your child’s health conditions. We do this through our disease management

programs. Members are provided education and personal help from Sunshine Health staff.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

The goal of this service is to add to the quality of your child’s care and help you and your

child to improve your child’s health.

If your child has one of the conditions below, call Member Services for information:

• Asthma

• Cancer

• Depression

• Diabetes

• HIV/AIDS

• Substance Abuse Disorder

All of our programs are geared toward helping you understand and actively manage

your child’s health. We are here to help you and your child with things like:

• How to take medicines

• What screening tests to get

• When to call your child’s doctor

• When to go to the Emergency Room

We will help you get the things your child needs. We will provide tools to help you and

your child learn and take control of your child’s condition. For more information, call

Member Services at 1-855-463-4100 and ask to speak with a case manager.

If your child is in the LTC program, we also offer programs for Dementia and

Alzheimer’s issues. Sunshine Health’s Alzheimer’s & Dementia program focuses on

LTC members diagnosed with these conditions. We will work with you and your child to

create a person-centered care plan that includes goals and interventions to address

your child’s needs.

This program is based on personal care planning and a team approach. It provides

education and help to voice the care that your child wants. It also helps you and your

child to understand the services and supports your child can get.

Advance Directives

Advance Directives are written instructions about the health care your child wants to

receive if he or she is unable to speak for himself or herself. Any Sunshine Health

member 18 years or older can make an advance directive to accept or refuse medical or

surgical treatment or withhold or remove life-giving care in the event of a terminal

condition. This also includes planning treatment before your child needs it. You can call

Member Services if you have questions or to ask for a copy of our policy. The number is

1-855-463-4100. Call them if you need help in finding the form. You can also talk to your

child’s PCP if you have any questions. Once the Advance Directive is finished, ask your

child’s PCP to put the form in your child’s file. You and your child can make changes to

your child’s directive when you want to. If the law changes, we will let you know within

90 days of any change.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

If your child’s Advance Directive is not being followed, you can call the state’s complaint

line at 1-888-419-3456.

Together, you and your child’s PCP can make decisions that will set your mind at ease.

It can help your child’s doctors understand your wishes about your child’s health.

Advance Directives will not take away your right to make your own decisions. They will

work only when your child is unable to speak for himself or herself. Your child will not be

treated differently for not having an Advance Directive. Sunshine Health does not limit

the implementation of advance directives as a matter of conscience.

Examples of Advance Directives include:

• Living Will

• Health Care Power of Attorney

• “Do Not Resuscitate” Orders

Quality Enhancement Programs

We want you to get quality health care. We offer additional programs that help make the

care you receive better. The programs are:

Well Child Visits

Children and young people need to see their doctor regularly even when they are not

sick. This chart shows when babies, children and young adults need to see their doctor

for a preventive health check. We don’t want your child to miss any key steps toward

good health as they grow.

Infancy

Health Check Schedule

• Birth

• 3-5 days

• By 1 month

• 2 months

• 4 months

• 6 months

Dental Exam

• When first tooth shows,

no later than 12 months

• Repeat every six

months

Early Childhood

Health Check Schedule

• 12 months

• 15 months

• 18 months

• 24 months

• 30 months

• 3 years

Dental Exam

• Every six months

Middle Childhood &

Adolescence

Health Check Schedule

• Every year until age 21

Dental Exam

• Every six months

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Doctors and nurses will examine your child or teenager. They will give shots for

diseases when necessary. Shots are important to keep your child healthy. They will also

ask questions about health problems and tell you what to do to stay healthy. If there is a

problem found during the checkup, your doctor can send you to a specialist. To

schedule a Well Child Visit, call your doctor. If you have problems getting a visit, please

call Member Services at 1-855-463-4100.

Domestic Violence

If you are facing abuse or suffered abuse in the past, please talk to your doctor or your

case manager to find a local program in your community to get help in a safe and

private setting.

Pregnancy Prevention

Sunshine Health’s pregnancy prevention program brings together existing community

programs to talk to members. Doctors team up with these programs to give more facts

around pregnancy, sexual transmitted diseases and contraceptive methods. Some of

the organizations Sunshine Health partners with are Duval County Health Department,

Catholic Charities, Planned Parenthood, Healthy Start, Oasis Pregnancy Center, Hope

for Miami, Project U-Turn and Plan Be Trinity Church Teen Pregnancy Prevention

Program. If you want help with pregnancy prevention, your doctor or your case

manager can help you find a local program in your community.

Case Management

We understand some members have special needs. Most children in the Child Welfare

System have special needs as a result of the trauma, abuse, or neglect they have

experienced. Sunshine Health’s Child Welfare Specialty Plan offers our members case

management services to help members with special health care needs. This service is

for members, parents, foster parents, adoptive parents, or other caregivers who may

need more help in taking care of their child’s health or understanding their child’s health

care needs.

Your child may have a Dependency Case Manager at your local CBC. If your child has

complex special needs, significant behavioral health needs, or a disability, Sunshine

Health‘s case managers can help support you and the Dependency Case Manager

working with your child. Our case managers are registered nurses or clinical social

workers. They can help you understand your child’s major health problems. They can

also arrange care with your child’s doctors or behavioral health providers. A case

manager will work with your Dependency Case Manager, you and your child’s PCP,

specialists or behavioral health provider. They can help you get the care your child

needs. Case managers can talk to your doctors, help schedule appointments and

coordinate your child’s care, including home health or other needed services.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Sunshine Health’s case management team is also available to connect you and your

child to needed community resources, such as food banks, WIC services, or housing

support.

Member Services can give you more information about Sunshine Health’s case

management services. Call 1-855-463-4100 for more information. You can ask to speak

to a case manager.

For our Child Welfare Specialty Plan members, we offer special case management

programs including:

• Support if your child has many health conditions and sees many doctors

• Health Coaching for certain medical or behavioral health conditions

• Intellectual and developmental disabilities management

• Promoting Adoption Success

• Start Smart for Your Baby for pregnancy

• Transitioning Youth

• Human Trafficking/Commercial Sexual Exploitation of Children

• Crisis Prevention

Caregiver Training

To provide extra support to caregivers of our members, Sunshine Health Child Welfare

Specialty Plan provides extensive training. This training is offered to all caregivers

including foster parents, adoptive parents, relative caregivers, biological parents and

other caregivers. We offer training on many topics, such as, Trauma Informed Care and

other trauma training, Hope for Healing, Human Trafficking, Bullying, De-escalation,

Dealing with Grief, Helping the Helper, Working with LGBTQ Youth in Care, Toxic

Stress, Parenting and Working with Biological Parents.

Enhancing Transitional Services Program

Youth who are transitioning out of the foster care system may need help in many areas.

Those areas can include finding a place to live, finishing education, managing money

and getting a job. These members may need help finding new medical or behavioral

health providers and making appointments.

This program will:

• Link to the health resources he or she needs

• Educate on how to get needed health care through the Medicaid system,

understand what health care benefits are available and living a healthy life style

• Connect to independent living support programs in their communities

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Promoting Adoption Success Program

The needs of children who have been adopted from the child welfare system will

change as they grow. Our staff help arrange physical and behavioral health care for

your adopted child and provide supports to help families stay together. They can help

you find providers for your child that have experience caring for adopted children. They

can connect you to community resources that can help.

Healthy Teen Pregnancy Program

Sunshine Health wants to help our members who are pregnant to have a healthy

pregnancy and healthy baby. We connect pregnant members to our Start Smart for

Your Baby

pregnancy program. Our staff can help your child get prenatal care early

and find the right providers who can care for their pregnancy and other medical or

behavioral health conditions.

Healthy Start Partnerships

Sunshine Health has teamed up with Healthy Start Coalitions to help pregnant members

set up services. Our Healthy Start partners can speak with you in your community and

help with prenatal care. This program educates and supports pregnant members who

are at risk to have difficult births. We will explain the role of prenatal visits to the health

of your baby, help with making your appointments and link you with agencies, like

Healthy Start and WIC, while making more community referrals. Our maternity case

managers will work with you at the start of your pregnancy until after you give birth. If

you need help with your pregnancy, please let your doctor or case manager know to

begin this program.

Nutritional Assessment and Counseling

Sunshine Health wants to help you and your family eat healthy. We can help find local

food pantries, markets and food programs near you. If you need help with food, tell your

doctor. With your doctor, you will be able to make a plan for a better diet and get help

with referrals to local WIC offices, if needed. You will get a copy of the referrals, diet and

nutrition plans you make with the Healthy Start nutritionist. Then, a case manager will

follow up with you to assist with any issues you have and help you find more local

resources to help you get the services needed to follow your plan, even if the services

are outside of what Medicaid covers.

Behavioral Health

Sunshine Health case managers can help find local mental health services and

community resources to lower your risk of going to the hospital or getting involved with

the justice system due to your mental health. By telling your case manager your need

for this help, your case manager can explain future risk of you and/or your child’s role

with the justice system by asking you questions about risky behaviors. Your case

manager will also help find shelters, food and other needs that may be adding to your

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

risky behaviors. If needed, the case manager will make referrals and help schedule

appointments with local providers to help decrease risky behaviors and get the help

needed.

You also have a right to tell us about changes you think we should make.

To get more information about our quality enhancement program or to give us your

ideas, call Member Services at 1-855-463-4100.

Child Welfare Advisory Committee

We want to give our members the best health care services. We have a Child Welfare

Advisory Committee that gives members, foster parents, adoptive parents, guardians of

children who are members and member advocates a chance to talk about their thoughts

and ideas with Sunshine Health’s Child Welfare Specialty Plan. At these meetings,

members, caregivers and other advocates have a chance to talk about the way services

are delivered.

The group meets four times a year. We may ask members, providers, member

advocates and Sunshine Health staff to join in the meeting. This gives members a

chance to talk about ideas or concerns as a member of our Plan. The members of our

Child Welfare Advisory Committee have a chance to tell us how we are doing. They

may ask questions. They may share any concerns about the delivery of services.

You also have a right to tell us about changes you think we should make.

To get more information about our Child Welfare Advisory Committee, call Member

Services at 1-855-463-4100.

Section 12: Your Plan Benefits: Managed Medical Assistance Services

The table on the next page lists the medical services that are covered by our Plan.

Remember, your child may need a referral from your child’s PCP or approval from us

before you go to an appointment or use a service. Services must be medically

necessary in order for us to pay for them

There may be some services that we do not cover, but might still be covered by

Medicaid. To find out about these benefits, call the Agency Medicaid Help Line at

1-877-254-1055. If you need a ride to any of these services, we can help you. You can

call 1-877-659-8420 to schedule a ride.

You can find the definition for Medical Necessity at

http://ahca.myflorida.com/medicaid/review/General/59G_1010_Definitions.pdf

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

If there are changes in covered services or other changes that will affect you, we will

notify you in writing at least 30 days before the effective date of the change.

If you have questions about any of the covered medical services, please call Member

Services.

NOTE: Services highlighted are behavioral health in lieu of services. This means they

are optional services you can choose over more traditional services based on your

individual needs.

Except for emergency care, Sunshine Health must prior authorize any services to

out-of-network providers and any elective inpatient admissions.

Service

Description

Coverage/Limitations

Prior

Authorization

Allergy Services

Services to treat

conditions such as

sneezing or rashes

that are not caused

by an illness.

We cover blood or skin

allergy testing and up to 156

doses per calendar year of

allergy shots.

Ambulance

Transportation

Services

Ambulance services

are for when you

need emergency

care while being

transported to the

hospital or special

support when being

transported

between facilities.

Covered as medically

necessary.

Ambulatory

Detoxification

Services

Substance abuse

detoxification

services that are

performed in a

facility that is not a

hospital.

For members under age 21:

Up to 3 hours per day and no

limit per calendar year.

For members over age 21: Up

to 3 hours per day for up to

30 days per calendar year.

Yes

Ambulatory

Surgical Center

Services

Surgery and other

procedures that are

performed in a

facility that is not

the hospital

(outpatient).

Covered as medically

necessary.

Yes, for some

procedures.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Anesthesia

Services

Services to keep

you from feeling

pain during surgery

or other medical

procedures.

Covered as medically

necessary.

Yes, for dental

procedures not

done in an

office.

Assistive Care

Services

Services provided

to adults (ages 18

and older) to help

with activities of

daily living and

taking medication.

We cover 365/366 days of

services per calendar year.

Yes

Behavioral

Health

Assessment

Services

Services used to

detect or diagnose

mental illnesses

and behavioral

health disorders.

We cover:

- One initial assessment per

calendar year

- One reassessment per

calendar year

- Up to 150 minutes of brief

behavioral health status

assessments (no more

than 30 minutes in a

single day)

Yes

Behavioral

Health Overlay

Services

Services provided in

a group home

setting for children

ages 0 – 21 who

have experienced

trauma and are in

the child welfare

system.

We cover 365/366 days of

services per calendar year.

Yes

Cardiovascular

Services

Services that treat

the heart and

circulatory (blood

vessels) system.

We cover the following as

prescribed by your doctor:

- Cardiac testing

- Cardiac surgical

procedures

- Cardiac devices

Yes, for some

services.

Child Health

Services

Targeted Case

Management

Services provided

to children ages 0 -

3 to help them get

health care and

other services.

Your child must be enrolled in

the DOH Early Steps

program.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Chiropractic

Services

Diagnosis and

manipulative

treatment of

misalignments of

the joints, especially

the spinal column,

which may cause

other disorders by

affecting the nerves,

muscles and

organs.

We cover:

- 24 established patient

visits per calendar year,

per member.

- X-rays.

Clinic Services

Health care

services provided in

a county health

department,

federally qualified

health center, or a

rural health clinic.

Services must be provided in

a county health department,

federally qualified health

center or a rural health clinic.

Community-

Based Wrap-

Around Services

Individualized care

planning and care

management

service to support

children with

complex needs who

are at risk of

placement in a

mental health

treatment facility.

Children and youth up to age

21.

One per day with no limits per

calendar year.

Yes

Crisis

Stabilization Unit

Services

Emergency mental

health services that

are performed in a

facility that is not a

regular hospital.

All ages.

One per day and no limit per

calendar year.

No prior

authorization

required for the

first day.

After the first

day, prior

authorization

required.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Detoxification or

Addictions

Receiving

Facility Services

Emergency

substance abuse

services that are

performed in a

facility that is not a

regular hospital.

All ages.

Up to a total of 15 days per

month.

No prior

authorization

required for the

first day.

After the first

day, prior

authorization

required.

Dialysis

Services

Medical care, tests

and other

treatments for the

kidneys. This

service also

includes dialysis

supplies and other

supplies that help

treat the kidneys.

We cover the following as

prescribed by your treating

doctor:

- Hemodialysis treatments

- Peritoneal dialysis

treatments

Drop-In Center

Services

A social club

offering peer

support and a

flexible schedule of

activities.

Ages 18 and older.

Maximum of 20 days per

calendar year.

Yes

Durable Medical

Equipment and

Medical

Supplies

Services

Medical equipment

is used to manage

and treat a

condition, illness, or

injury. Durable

medical equipment

is used over and

over again, and

includes things like

wheelchairs,

braces, crutches

and other items.

Medical supplies

are items meant for

one-time use and

then thrown away.

Some service and age limits

apply. Call 1-855-463-4100

(TTY: 1-800-955-8770) for

more information.

Yes, for some

equipment or

services.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Early

Intervention

Services

Services to children

ages 0 - 3 who have

developmental

delays and other

conditions.

We cover:

- One initial evaluation per

lifetime, completed by a

team

- Up to 3 screenings per

calendar year

- Up to 3 follow-up

evaluations per calendar

year

Up to 2 training or support

sessions per week

Emergency

Transportation

Services

Transportation

provided by

ambulances or air

ambulances

(helicopters or

airplanes) to get

you to a hospital

because of an

emergency.

Covered as medically

necessary.

Evaluation and

Management

Services

Services for

doctor’s visits to

stay healthy and

prevent or treat

illness.

We cover:

- One adult health

screening (check-up) per

calendar year

- Well Child Visits are

provided based on age

and developmental needs

- One visit per month for

people living in nursing

facilities

- Up to two office visits per

month for adults to treat

illnesses or conditions

Family Therapy

Services

Services for families

to have therapy

sessions with a

mental health

professional.

Up to 26 hours per calendar

year

Yes, after 12

sessions.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Family Training

and Counseling

for Child

Development

Educational services

for family members of

children with severe

emotional problems

focused on child

development and

other family support.

Ages 0 to 21.

Up to a total of 9 hours per

month.

Yes

Gastrointestinal

Services

Services to treat

conditions, illnesses,

or diseases of the

stomach or digestion

system.

Covered as medically

necessary.

Yes, for some

services.

Genitourinary

Services

Services to treat

conditions, illnesses,

or diseases of the

genitals or urinary

system.

Covered as medically

necessary.

Yes, for some

services.

Group Therapy

Services

Services for a group

of people to have

therapy sessions with

a mental health

professional.

We cover:

- Up to 39 hours per

calendar year for adults

ages 21 and over

- For children up to age

21 there are no limits if

medically necessary

Yes

Hearing

Services

Hearing tests,

treatments and

supplies that help

diagnose or treat

problems with your

hearing. This includes

hearing aids and

repairs.

We cover hearing tests and

the following as prescribed

by your doctor:

- Cochlear implants

- One new hearing aid per

ear, once every 3 years

- Repairs

Yes, for some

services.

Home Health

Services

Nursing services and

medical assistance

provided in your

home to help you

manage or recover

from a medical

condition, illness or

injury.

We cover:

- Up to 4 visits per day for

pregnant members and

members ages 0 to 20

- Up to 3 visits per day for

all other members

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Hospice

Services

Medical care,

treatment and

emotional support

services for people

with terminal illnesses

or who are at the end

of their lives to help

keep them

comfortable and pain

free. Support services

are also available for

family members or

caregivers.

Covered as medically

necessary.

Yes

Individual

Therapy

Services

Services for people to

have one-on-one

therapy sessions with

a mental health

professional.

We cover:

- Up to 26 hours per

calendar year for adults

ages 21 and over.

- For children up to 21

there are no limits if

medically necessary

Yes, after 12

sessions.

Infant Mental

Health Pre and

Post Testing

Services

Testing services by a

mental health

professional with

special training in

infants and young

children.

For children ages 0 to 5

years only.

40 units per calendar year.

(1 unit = 15 minutes)

Yes

Inpatient

Hospital

Services

Medical care that you

get while you are in

the hospital. This can

include any tests,

medicines, therapies

and treatments, visits

from doctors and

equipment that is

used to treat you.

We cover the following

inpatient hospital services

based on age and situation:

- Up to 365/366 days for

members ages 0-20

- Up to 45 days for all

other members (extra

days are covered for

emergencies)

Yes

Integumentary

Services

Services to diagnose

or treat skin

conditions, illnesses

or diseases.

Covered as medically

necessary.

Yes, for some

services.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Laboratory

Services

Services that test

blood, urine, saliva or

other items from the

body for conditions,

illnesses or diseases.

Covered as medically

necessary.

Yes, for some

services.

Medical Foster

Care Services

Services that help

children with health

problems who live in

foster care homes.

Must be in the custody of

the Department of Children

and Families.

Medication

Assisted

Treatment

Services

Services used to help

people who are

struggling with drug

addiction.

Covered as medically

necessary.

Medication

Management

Services

Services to help

people understand

and make the best

choices for taking

medication.

Covered as medically

necessary.

Mental Health

Targeted Case

Management

Services to help get

medical and

behavioral health

care for people with

mental illnesses.

Covered as medically

necessary.

Yes

Mobile Crisis

Assessment and

Intervention

Services

A team of health care

professionals who

provide emergency

mental health

services in the home,

community, or school.

All ages.

96 units per calendar year.

Maximum of 8 units per day.

(1 unit = 15 minutes)

Neurology

Services

Services to diagnose

or treat conditions,

illnesses or diseases

of the brain, spinal

cord or nervous

system.

Covered as medically

necessary.

Yes, for some

services.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Non-Emergency

Transportation

Services

Transportation to

and from all of your

medical

appointments. This

could be on the bus,

a van that can

transport people

with disabilities, a

taxi, or other kinds

of vehicles.

We cover the following

services for those who have

no transportation:

- Out-of-state travel

- Transfers between

hospitals or facilities

- Escorts when medically

necessary

Yes, for any trip

over 100 miles.

Nursing Facility

Services

Medical care or

nursing care that

you get while living

full-time in a nursing

facility. This can be

a short-term

rehabilitation stay or

long-term.

- We cover 365/366 days of

services in nursing

facilities as medically

necessary.

- See information on Patient

Responsibility for room &

board.

Yes

Occupational

Therapy

Services

Occupational

therapy includes

treatments that help

you do things in

your daily life, like

writing, feeding

yourself and using

items around the

house.

We cover for children ages 0

to 20 and for adults under the

$1,500 outpatient services

cap:

- One initial evaluation per

calendar year

- Up to 210 minutes of

treatment per week

- One initial wheelchair

evaluation per 5 years

We cover for people of all

ages:

- Follow-up wheelchair

evaluations, one at

delivery and one 6 months

later

Yes, for some

services.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Oral Surgery

Services

Services that

provide teeth

extractions

(removals) and to

treat other

conditions, illnesses

or diseases of the

mouth and oral

cavity.

Covered as medically

necessary.

Yes, for some

services.

Orthopedic

Services

Services to

diagnose or treat

conditions, illnesses

or diseases of the

bones or joints.

Covered as medically

necessary.

Yes, for some

services.

Outpatient

Hospital

Services

Medical care that

you get while you

are in the hospital

but are not staying

overnight. This can

include any tests,

medicines,

therapies and

treatments, visits

from doctors and

equipment that is

used to treat you.

- Emergency services are

covered as medically

necessary.

- Non-emergency services

cannot cost more than

$1,500 per year for

recipients ages 21 and

over.

Yes, for some

services.

Pain

Management

Services

Treatments for long-

lasting pain that

does not get better

after other services

have been

provided.

Covered as medically

necessary. Some service

limits may apply.

Yes

Partial

Hospitalization

Services

Structured mental

health treatment

services provided in

a hospital 4-6 hours

each day for 5 days

per week.

All ages.

One per day and no limit per

calendar year.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Physical

Therapy

Services

Physical therapy

includes exercises,

stretching and other

treatments to help

your body get

stronger and feel

better after an

injury, illness or

because of a

medical condition.

We cover for children ages 0-20

and for adults under the $1,500

outpatient services cap:

- One initial evaluation per

year.

- Up to 210 minutes of

treatment per week.

- One initial wheelchair

evaluation per 5 years.

We cover for people of all ages:

- Follow-up wheelchair

evaluations, one at

delivery and one 6-months

later.

Yes, for some

services.

Podiatry

Services

Medical care and

other treatments for

the feet.

We cover:

- Up to 24 office visits per

calendar year

- Foot and nail care

- X-rays and other imaging

for the foot, ankle and

lower leg

- Surgery on the foot, ankle

or lower leg

Yes, for some

services.

Prescribed Drug

Services

This service is for

drugs that are

prescribed to you by

a doctor or other

health care

provider.

We cover:

- Up to a 34-day supply of

drugs, per prescription

- Refills, as prescribed

Yes, for some

drugs.

Private Duty

Nursing

Services

Nursing services

provided in the

home to members

0-20 who need

constant care.

Up to 24 hours per day.

Yes

Psychological

Testing Services

Tests used to detect

or diagnose

problems with

memory, IQ or other

areas.

10 hours of psychological

testing per calendar year.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Psychosocial

Rehabilitation

Services

Services to assist

people to re-enter

everyday life. They

include help with

basic activities such

as cooking,

managing money

and performing

household chores.

Up to 480 hours per calendar

year.

Yes

Radiology and

Nuclear

Medicine

Services

Services that

include imaging

such as x-rays,

MRIs or CAT scans.

They also include

portable x-rays.

Covered as medically

necessary.

Yes, for some

services

Regional

Perinatal

Intensive Care

Center Services

Services provided

to pregnant women

and newborns in

hospitals that have

special care centers

to handle serious

conditions.

Covered as medically

necessary.

Yes, for some

services

Reproductive

Services

Services for women

who are pregnant or

want to become

pregnant. They also

include family

planning services

that provide birth

control drugs and

supplies to help you

plan the size of your

family.

We cover family planning

services. You can get these

services and supplies from

any Medicaid provider; they

do not have to be a part of

our Plan. You do not need

prior approval for these

services. These services are

free. These services are

voluntary and confidential,

even if you are under 18

years old.

Residential

Outpatient

Treatment

Short term

residential

treatment program

for pregnant

women with

substance use

disorder

Ages 21 and older

Up to 60 days/calendar year

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Respiratory

Services

Services that treat

conditions, illnesses

or diseases of the

lungs or respiratory

system.

We cover:

- Respiratory testing

- Respiratory surgical

procedures

- Respiratory device

management

Yes, for some

services.

Respiratory

Therapy

Services

Services for

members ages 0-20

to help you breathe

better while being

treated for a

respiratory

condition, illness or

disease.

We cover:

- One initial evaluation per

calendar year

- One therapy re-evaluation

per 6 months

- Up to 210 minutes of

therapy treatments per

week (maximum of 60

minutes per day)

Self-Help/Peer

Services

Support services for

people with mental

health or substance

use conditions

provided by

someone with

similar experiences

but who is in

recovery.

All ages.

Up to 16 units per day

(1 unit = 15 minutes)

Yes

Skilled Nursing

Medical care or

skilled nursing care

that you get while

you are in a nursing

facility.

This can be a short-

term or long-term

rehabilitation stay.

All ages.

Up to 60 days per calendar.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Specialized

Therapeutic

Services

Services provided

to children ages

0-21 with mental

illnesses or

substance use

disorders.

For children under the age of

21, we cover:

- Comprehensive

Behavioral Health

Assessments

- Specialized Therapeutic

Foster Care Services

- Therapeutic Group home

services

Yes

Speech-

Language

Pathology

Services

Services that

include tests and

treatments to help

you to talk or

swallow better.

We cover the following

services for children ages

0 to 20:

- Communication devices

and services

- Up to 210 minutes of

treatment per week

- One initial evaluation per

calendar year

We cover the following

services for adults:

- One communication

evaluation per 5 years

Yes

Statewide

Inpatient

Psychiatric

Program

Services

Services for

children with severe

mental illnesses

that need treatment

in a secured facility.

Covered as medically

necessary for ages 0 to 20.

Yes

Therapeutic

Behavioral On-

Site Services

Therapeutic

services provided in

the home or

community to

prevent children

with mental

illnesses from being

placed in a hospital

or other facility.

Ages 0 to 20.

Up to 9 hours per month.

Yes

Transplant

Services

Services that

include all surgery

and pre- and post-

surgical care.

Covered as medically

necessary.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Visual Aid

Services

Visual Aids are

items such as

glasses, contact

lenses and

prosthetic (fake)

eyes.

We cover the following

services when prescribed by

your doctor:

- Two pairs of eyeglasses

for children ages 0-20

- Contact lenses

- Prosthetic eyes

Yes, for some

services.

Visual Care

Services

Services that test

and treat conditions,

illnesses and

diseases of the

eyes.

Covered as medically

necessary.

Yes, for some

services.

American Indian members are not asked to pay copayments.

Your Plan Benefits: Expanded Benefits

Expanded benefits are extra goods or services we provide to you, free of charge. Call

Member Services to ask about getting expanded benefits.

Service

Description

Coverage/Limitations

Prior

Authorization

Care grant

Up to $150 per calendar

year per child for

services or supplies for

social use or physical

activities.

Ages 0 to 21.

Up to $150 per

calendar year.

Yes

CVS discount

program

20% discount on certain

over-the-counter items.

All ages.

Doula services

Pregnancy, postpartum

and newborn care and

assessment provided in

your home by a Doula.

Ages 13 and older.

No limits.

Yes

Durable medical

equipment – breast

pump

• Breast pump,

hospital grade

rental

• Breast pump

rental

1 per calendar year;

ages 10 to 59.

1 per 2 calendar years;

ages 10 to 59.

Yes

Home delivered

meals post

inpatient discharge

Meals delivered to your

home after a

hospitalization.

Ages 0 to 21.

No limits.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Life Skills

Development

For children or

adolescents with

developmental

disabilities to provide life

skills help for the child or

adolescent to keep,

learn or improve skills

and functioning for daily

living. These services

will be provided in the

home or outpatient

setting.

Ages 12 to 21.

Must have a diagnosed

developmental

disability.

Up to 160 hours per

calendar year.

Yes

Newborn

circumcision

Can be provided in a

hospital, office or

outpatient setting.

Birth to 28 days old.

1 per lifetime if

medically necessary.

Non-emergency

transportation –

non-medical

purposes

Transportation provided

for non-medical

purposes such as social

outings or family visits.

Ages 5 to 21.

Three round-trips per

month.

Yes

Non-emergency

transportation

meals

Meals as part of a non-

medical transportation

trip.

Ages 0 to 21.

Up to $200 per day up

to $1,000 per calendar

year for trips over 100

miles.

Yes

Over-the-counter

benefit

Up to $25 per

household, per month,

for cold, cough, allergy,

vitamins, supplements,

ophthalmic/otic

preparations, pain

relievers, gastrointestinal

products, first aid care,

hygiene products, insect

repellant, oral hygiene

products and skin care.

Ages 0 to 21.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/Limitations

Prior

Authorization

Prenatal/perinatal

visits

Prenatal/perinatal office

visits for pregnant

women.

Ages 10 to 59.

14 visits for low-risk

pregnancy.

18 visits for high-risk

pregnancy.

Postpartum visits

Doctor visits after

delivery of your baby.

Ages 10 to 59.

Three visits within 90

days of delivery.

Transition

Assistance

One-time payment of up

to $500 per youth who is

transitioning out of foster

care at age 18 or out of

extended foster care at

age 21. Funds to

support moving to a new

home.

Ages 18 to 21.

Must be in out-of-home

licensed foster care for

a minimum of 6

months before

transitioning out of

foster care.

Yes

The plan will not charge a copayment. Also, there will be no cost sharing for all covered

services. This includes enhanced benefits.

Section 13: Long-Term Care Program Helpful Information

(Read this section if your child is in the LTC program. If your child is not in the

LTC program, skip to Section 15)

Starting Services

It is important that we learn about your child so we can make sure your child gets the

care that he or she needs. Your child’s case manager will set up a time to come to your

home or nursing facility to meet you.

At this first visit, your case manager will tell you about the LTC program and our Plan.

She or he will also ask you questions about your child’s health, how he or she takes

care of himself or herself, how your child spend his or her time, who helps takes care of

your child, and other things. These questions make up your child’s initial assessment.

The initial assessment helps us learn about what your child needs to live safely in your

home. It also helps us decide what services will help your child the most.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Developing a Plan of Care

Before your child can begin to get services under the LTC program, your child must

have a person-centered plan of care (plan of care). Your child’s case manager

makes your child’s plan of care. Your child’s plan of care is the document that tells you

all about the services your child gets from our LTC program. Your case manager will

talk to you and any family members or caregivers you want to include to decide what

LTC services will help. They will use the initial assessment and other information to

make a plan that is just for your child. Your child’s plan of care will tell you:

• What services your child is getting

• Who is providing your child’s service (your child’s service providers)

• How often your child gets a service

• When a service starts and when it ends (if it has an end date)

• What your child’s services are trying to help your child do. For example, if your

child needs help doing small chores around your house, your child’s plan of care

will tell you that an adult companion care provider comes 2 days a week to help

with your child’s chores.

• How your child’s LTC services work with other services your child gets from

outside our Plan, such as from Medicare, your church or other federal programs

• Your child’s personal goals

We don’t just want to make sure that your child is living safely. We also want to make

sure that your child is happy and feels connected to your community and other people.

When your case manager is making your child’s plan of care, they will ask you about

any personal goals your child might have. These can be anything, really, but we want

to make sure that your child’s LTC services help you accomplish your child’s goals.

Some examples of personal goals include:

• Walking for 10 minutes every day

• Calling a loved one once a week

• Moving from a nursing facility to an assisted living facility

You or your authorized representative (someone you trust who is allowed to talk to us

about your child’s care) must sign your child’s plan of care. This is how you show you

agree with the Plan and the services we decided.

Your case manager will send your PCP a copy of your child’s plan of care. They will

also share it with your child’s other health care providers.

Updating Your Plan of Care

Every month your case manager will call you to see how your child’s services are going

and how you are doing. If any changes are made, she or he will update your child’s plan

of care and get you a new copy.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Your case manager will come to see you in person to review your child’s plan of care

every 90 days (or about three months). This is a good time to talk to them about your

child’s services, what is working and isn’t working for your child, and how your child’s

goals are going. They will update your child’s plan of care with any changes. Every time

your child’s plan of care changes, you or your authorized representative must sign it.

Remember, you can call your case manager any time to talk about problems you have,

changes in your child’s life, or other things. Your case manager is available to you when

you need them.

Your Back-Up Plan

Your case manager will help you make a back-up plan. A back-up plan tells you what

to do if a service provider does not show up to give a service. For example, your home

health aide did not come to give your child a bath.

Remember, if you have any problems getting your child’s services, call your case

manager.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 14: Your Plan Benefits: Long-Term Care Services

The table below lists the Long-Term Care Services covered by our Plan. Remember,

services must be medically necessary in order for us to pay for them

If there are changes in covered services or other changes that will affect your child, we

will notify you in writing at least 30 days before the effective date of the change.

If you have any questions about any of the covered Long-Term Care Services, please

call your case manager or Member Services.

NOTE: Services highlighted are behavioral health in lieu of services. This means they

are optional services you can choose over more traditional services based on your

child’s individual needs.

Service

Description

Coverage/

Limitations

Prior

Authorization

Adult Day Care

Supervision, social

programs and activities

provided at an adult

day care center during

the day. If you are

there during meal

times, you can eat

there.

Per assessed need.

Yes

Assistive Care

Services

These are 24-hour

services if you live in

an adult family care

home or an assisted

living facility.

Limited to members who

reside in assisted living

facilities and adult family

care homes.

Yes

You can find a copy of the Statewide Medicaid Managed Care Long-Term Care

Program Coverage Policy at http://ahca.myflorida.com/medicaid/review/Specific/59G-

4.192_LTC_Program_Policy.pdf

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Assisted Living

These are services that

are usually provided in

an assisted living facility

(ALF). Services can

include housekeeping,

help with bathing,

dressing and eating,

medication assistance

and social programs.

Member is responsible for

paying ALF room and

board. The Florida Dept. of

Children and Families

(DCF) will evaluate the

member’s income to

determine if additional

payment is required by

member. If the member

resides in a room other

than a standard semi-

private room, the facility

may charge extra.

Family supplementation is

allowed to pay the

difference in cost between

a shared and private room

directly to the facility.

Yes

Attendant

Nursing Care

Nursing services and

medical assistance

provided in your home

to help you manage or

recover from a medical

condition, illness, or

injury.

Per assessed need.

Yes

Behavioral

Management

Services for mental

health or substance

abuse needs.

Per assessed need.

Yes

Caregiver

Training

Training and counseling

for the people who help

take care of you.

Per assessed need.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Care

Coordination/

Care

Management

Services that help you

get the services and

support you need to

live safely and

independently. This

includes having a case

manager and making a

plan of care that lists

all the services you

need and receive.

Available to all members.

Companion Care

This service helps you

fix meals, do laundry

and light

housekeeping.

Per assessed need.

Yes

Home

Accessibility/

Adaptation

Services

This service makes

changes to your home

to help you live and

move in your home

safely and more easily.

It can include changes

like installing grab bars

in your bathroom or a

special toilet seat. It

does not include major

changes like new

carpeting, roof repairs,

plumbing systems, etc.

Excludes those adaptations

or improvements to the

home that are of general

use and are not of direct

medical or remedial benefit

to the member.

Yes

Home Delivered

Meals

This service delivers

healthy meals to your

home.

Per assessed need.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Homemaker

Services

This service helps you

with general household

activities, like meal

preparation and routine

home chores.

Per assessed need.

Yes

Hospice

Medical care,

treatment and

emotional support

services for people

with terminal illnesses

or who are at the end

of their lives to help

keep them comfortable

and pain free. Support

services are also

available for family

members or

caregivers.

As medically needed.

Intermittent and

Skilled Nursing

Extra nursing help if

you do not need

nursing supervision all

the time or need it at a

regular time.

Per assessed need.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Medical

Equipment and

Supplies

Medical equipment is

used to help manage and

treat a condition, illness,

or injury. Medical

equipment is used over

and over again, and

includes things like

wheelchairs, braces,

walkers and other items.

Medical supplies are

used to treat and manage

conditions, illnesses, or

injury. Medical supplies

include things that are

used and then thrown

away, like bandages,

gloves and other items.

Personal toiletries, and

household items such as

detergent, bleach and paper

towels are covered as

medically necessary.

Yes

Medication

Administration

Help taking medications if

you can’t take medication

by yourself.

Per assessed need.

Yes

Medication

Management

A review of all of the

prescription and over-the-

counter medications you

are taking.

Per assessed need.

Yes

Nutritional

Assessment/Risk

Reduction

Services

Education and support for

you and your family or

caregiver about your diet

and the foods you need

to eat to stay healthy.

Per assessed need.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Nursing Facility

Services

Nursing facility services

include medical

supervision, 24-hour

nursing care, help with

day-to-day activities,

physical therapy,

occupational therapy and

speech-language

pathology.

Per assessed need.

Yes

Personal Care

These are in-home

services to help you with:

• Bathing

• Dressing

• Eating

• Personal Hygiene

Per assessed need.

Yes

Personal

Emergency

Response

Systems (PERS)

An electronic device that

you can wear or keep

near you that lets you

call for emergency help

anytime.

Limited to members who

live alone or who are alone

for significant parts of the

day who would otherwise

require extensive

supervision. Coverage is

provided when they are

essential to the health and

welfare of the member.

Yes

Respite Care

This service lets your

caregivers take a short

break. You can use this

service in your home, an

Assisted Living Facility

or a Nursing Facility.

Per assessed need.

Yes

Occupational

Therapy

Occupational therapy

includes treatments that

help you do things in

your daily life, like

writing, feeding yourself

and using items around

the house.

Determined through multi-

disciplinary assessment.

Yes

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Service

Description

Coverage/

Limitations

Prior

Authorization

Physical

Therapy

Physical therapy

includes exercises,

stretching and other

treatments to help your

body get stronger and

feel better after an injury,

illness, or because of a

medical condition.

Per assessed need.

Yes

Respiratory

Therapy

Respiratory therapy

includes treatments that

help you breathe better.

Per assessed

need.

Yes

Speech Therapy

Speech therapy includes

tests and treatments that

help you talk or swallow.

Determined

through multi-

disciplinary

assessment.

Yes

Transportation

Transportation to and

from all of your LTC

program services. This

could be on the bus, a

van that can transport

disabled people, a taxi,

or other kinds of

vehicles.

Per assessed

need.

Yes, if over 100

miles.

Long-Term Care Participant Direction Option

You may be offered the Participant Direction Option (PDO). You can use PDO if you

use any of these services and live in your home:

• Attendant care services

• Homemaker services

• Personal Care services

• Adult companion care services

• Intermittent and skilled nursing care services

PDO lets you self-direct your child’s services. This means you get to choose your

child’s service provider and how and when you get your child’s service. You have to

hire, train and supervise the people who work for you (your direct service workers).

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

You can hire family members, neighbors, or friends. You will work with a case manager

who can help you with PDO.

If you are interested in PDO, ask your case manager for more details. You can also ask

for a copy of the PDO Guidelines to read and help you decide if this option is the right

choice for you.

Your Plan Benefits: LTC Expanded Benefits

Expanded benefits are extra services we provide to you at no cost. Talk to your case

manager about getting expanded benefits.

Service

Description

Coverage/Limitations

Prior

Authorization

Assisted Living

Facility or Adult

Family Care Home

– Bed Hold Days

Services such as

personal care,

housekeeping,

medication

oversight and social

programs to assist

the member in an

assisted living

facility.

Ages 18 and older.

Beds can be held for

14 days, if the member

has resided in the

facility for a minimum

of 30 days between

episodes.

Non-emergency

Transportation –

Non-medical

Purposes

Transportation for

non-medical trips,

such as shopping

or social events.

Ages 18 and older.

One round trip per

month.

Transition

Assistance –

Nursing Facility to

Community Setting

Financial

assistance to

members residing

in a nursing home

who can transfer to

independent living

situations.

Ages 18 and older.

Up to $5,000 per

lifetime to assist

member in moving out

of a nursing facility.

Yes

Individual Therapy

Sessions for

Caregivers

Therapeutic

counseling for

primary caregivers

who reside with

LTC members in a

private home.

Ages 18 and older.

Unlimited.

Yes

The plan will not charge a copayment. Also, there will be no cost sharing for all covered

services. This includes enhanced benefits.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 15: Member Satisfaction

Complaints, Grievances and Plan Appeals

We want you to be happy with us and the care your child receives from our providers.

Let us know right away if at any time you are not happy with anything about us or our

providers. This includes if you do not agree with a decision we have made.

What You Can Do:

What We Will Do:

If you are not

happy with us

or our

providers, you

can file a

Complaint

Call us at any time.

1-855-463-4100

Try to solve your issue within one

business day.

If you are not

happy with us

or our

providers, you

can file a

Grievance

• Write us or call us at any time

at 1-855-463-4100 (phone) or

TTY at 1-800-955-8770

• Call us to ask for more time to

solve your grievance if you

think more time will help.

Sunshine Health

P.O. Box 459087

Fort Lauderdale, FL

33345-9087

1-855-463-4100

Fax: 1-866-534-5972

Sunshine_Appeals@centene.com

• Review your grievance and

send you a letter with our

decision within 90 days

unless clinically urgent and

a response will be received

within 72 hours.

• If we need more time to

solve your grievance, we

will:

o Send you a letter with

our reason and tell

you about your rights

if you disagree.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

What You Can Do:

What We Will Do:

If you do not

agree with a

decision we

made about

your services,

you can ask for

an Appeal

• Write us, or call us and follow

up in writing, within 60 days of

our decision about your

services – 1-855-463-4100

(phone) or TTY at 1-800-955-

8770.

• Ask for your services to

continue within 10 days of

receiving our letter, if needed.

Some rules may apply.

Sunshine Health

P.O. Box 459087

Fort Lauderdale, FL

33345-9087

1-855-463-4100

Fax: 1-866-534-5972

Sunshine_Appeals@centene.com

• Send you a letter within five

business days to tell you we

received your appeal.

• Help you complete any

forms.

• Review your appeal and

send you a letter within 30

days to answer you.

If you think

waiting for 30

days will put

your health in

danger, you

can ask for an

Expedited or

“Fast” Appeal

• Write us or call us within 60

days of our decision about

your services.

Sunshine Health

P.O. Box 459087

Fort Lauderdale, FL

33345-9087

1-855-463-4100

• Give you an answer within

48 hours after we receive

your request.

• Call you the same day if we

do not agree that you need

a fast appeal, and send you

a letter within two days.

If you do not

agree with our

appeal

decision, you

can ask for a

Medicaid Fair

Hearing

• Write to the Agency for Health

Care Administration Office of

Fair Hearings.

• Ask us for a copy of your

medical record.

• Ask for your services to

continue within 10 days of

receiving our letter, if needed.

Some rules may apply.

**You must finish the appeal

process before you can have a

Medicaid Fair Hearing.

• Provide you with

transportation to the

Medicaid Fair Hearing, if

needed.

• Restart your services if the

State agrees with you.

If you continued your services,

we may ask you to pay for the

services if the final decision is

not in your favor.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Fast Plan Appeal

If we deny your request for a fast appeal, we will transfer your appeal into the regular

appeal time frame of 30 days. If you disagree with our decision not to give you a fast

appeal, you can call us to file a grievance.

Medicaid Fair Hearings (for Medicaid Members)

You may ask for a fair hearing at any time up to 120 days after you get a Notice of Plan

Appeal Resolution by calling or writing to:

Agency for Health Care Administration

Medicaid Fair Hearing Unit

P.O. Box 60127

Fort Meyers, FL 33906

1-877-254-1055 (toll-free)

1-239-338-2642 (fax)

MedicaidFairHearingUnit@ahca.myflorida.com

If you request a fair hearing in writing, please include the following information:

• Your child’s name

• Your child’s member number

• Your child’s Medicaid ID number

• A phone number where you or your representative can be reached

You may also include the following information, if you have it:

• Why you think the decision should be changed

• Any medical information to support the request

• Who you would like to help with your fair hearing

After getting your fair hearing request, the Agency will tell you in writing that they got

your fair hearing request. A hearing officer who works for the State will review the

decision we made.

If you are a Title XXI MediKids member, you are not allowed to have a Medicaid Fair

Hearing.

Review by the State (for MediKids Members)

When you ask for a review, a hearing officer who works for the State reviews the

decision made during the Plan appeal. You may ask for a review by the State any time

up to 30 days after you get the notice. You must finish your appeal process first.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

You may ask for a review by the State by calling or writing to:

Agency for Health Care Administration

P.O. Box 60127

Fort Myers, FL 33906

1-877 254-1055 (toll-free)

1-239-338-2642 (fax)

MedicaidHearingUnit@ahca.myflorida.com

After getting your request, the Agency will tell you in writing that they got your request.

Continuation of Benefits for Medicaid Members

If your child is now getting a service that is going to be reduced, suspended or

terminated, you have the right to keep getting those services until a final decision is

made for your Plan appeal or Medicaid fair hearing. If your child’s services are

continued, there will be no change in your services until a final decision is made.

If your child’s services are continued and our decision is not in your favor, we may ask

that you pay for the cost of those services. We will not take away your child’s Medicaid

benefits. We cannot ask your family or legal representative to pay for the services.

To have your child’s services continue during your appeal or fair hearing, you must file

your appeal and ask to continue services within this timeframe, whichever is later:

• 10 days after you receive a Notice of Adverse Benefits Determination (NABD), or

• On or before the first day that your child’s services will be reduced, suspended or

terminated

Section 16: Your Child’s Member Rights

As a member of Medicaid and a member in a Plan, your child also has certain rights.

You and your child have the right to:

• Be treated with courtesy and respect

• Have your dignity and privacy considered and respected at all times

• Receive a quick and useful response to your questions and requests

• Know who is providing medical services and who is responsible for your child’s

care

• Know what member services are available, including whether an interpreter is

available if you do not speak English

• Know what rules and laws apply to your conduct

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

• Be given easy to follow information about your child’s diagnosis, the treatment

you need, choices of treatments and alternatives, risks and how these treatments

will help you

• Make choices about your health care and say no to any treatment, except as

otherwise provided by law

• Be given full information about other ways to help pay for your child’s health care

• Know if the provider or facility accepts the Medicare assignment rate

• To be told prior to getting a service how much it may cost you

• Get a copy of a bill and have the charges explained to you

• Get medical treatment or special help for people with disabilities, regardless of

race, national origin, religion, handicap, gender, sexual orientation, gender

identify or source of payment

• Receive treatment for any health emergency that will get worse if your child does

not get treatment

• Know if medical treatment is for experimental research and to say yes or no to

participating in such research

• Make a complaint when your rights are not respected

• Ask for another doctor when you do not agree with your child’s doctor (second

medical opinion)

• Get a copy of your child’s medical record and ask to have information added or

corrected in your child’s record, if needed

• Have your child’s medical records kept private and shared only when required by

law or with your approval

• Decide how you want medical decisions made if you or your child can’t make

them yourself (advance directive)

• To file a grievance about any matter other than a Plan’s decision about your

child’s services

• To appeal a Plan’s decision about your child’s services

• Receive services from a provider that is not part of our Plan (out-of-network) if we

cannot find a provider for your child that is part of our Plan

• Speak freely about your health care and concerns without any bad results

• Freely exercise your rights without the Plan or its network providers treating you

badly

• Be free from any form of restraint or seclusion used as a means of coercion,

discipline, convenience or retaliation

• Request and receive a copy of your medical records and ask that they be

amended or corrected

LTC Members have the right to:

• Receive services in a home-like environment regardless where your child lives

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

• Receive information about being involved in your child’s community, setting

personal goals and how you can participate in that process

• Be told where, when and how to get the services your child need

• To be able to take part in decisions about your child’s health care

• To talk openly about the treatment options for your child’s conditions, regardless

of cost or benefit

• To choose the programs your child participates in and the providers that give

your child care

Section 17: Your Member Responsibilities

As a recipient of Medicaid and a member in a Plan, your child also has certain

responsibilities. You have the responsibility to:

• Give accurate information about your child’s health to your Plan and providers

• Tell your provider about unexpected changes in your child’s health condition

• Talk to your child’s provider to make sure you understand a course of action and

what is expected of you

• Listen to your child’s provider, follow instructions and ask questions

• Keep your appointments or notify your provider if you will not be able to keep an

appointment

• Be responsible for your actions if treatment is refused or if you do not follow the

health care provider's instructions

• Make sure payment is made for non-covered services you receive

• Follow health care facility conduct rules and regulations

• Treat health care staff with respect

• Tell us if you have problems with any health care staff

• Use the emergency room only for real emergencies

• Notify your case manager if your child has a change in information (address,

phone number, etc.)

• Have a plan for emergencies and access this plan if necessary for your child’s

safety

• Report fraud, abuse and overpayment

• Understand your child’s health problems and participate in developing mutually

agreed upon goals

LTC Members have the responsibility to:

• Tell your case manager if you want to disenroll from the Long-Term Care

program

• Agree to and participate in the annual face-to-face assessment, quarterly face-to-

face visits and monthly telephone contact with your case manager

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 18: Other Important Information

Patient Responsibility for Long-Term Care (LTC) or Hospice Services

If you receive LTC or hospice services, you may have to pay a “share in cost” for your

services each month. This share in cost is called “patient responsibility.” The

Department of Children and Families (DCF) will mail you a letter when you become

eligible (or to tell you about changes) for Medicaid LTC or hospice services. This letter

is called a “Notice of Case Action” or “NOCA.” The NOCA letter will tell you your dates

of eligibility and how much you must pay the facility where you live, if you live in a

facility, towards your share in the cost of your LTC or hospice services.

To learn more about patient responsibility, you can talk to your LTC case manager,

contact the DCF by calling 1-866-762-2237 toll-free, or visit the DCF Web page at

https://www.myflfamilies.com/service-programs/access/medicaid.shtml (scroll down to

the Medicaid for Aged or Disabled section and select the document entitled ‘SSI-

Related Fact Sheets’).

Indian Health Care Provider (IHCP) Protection

Indians are exempt from all cost sharing for services furnished or received by an IHCP

or referral under contract health services.

Emergency Disaster Plan

Disasters can happen at any time. To protect yourself and your family, it is important to

be prepared. There are three steps to preparing for a disaster: 1) Be informed; 2) Make

a Plan and 3) Get a Kit. For help with your emergency disaster plan, call Member

Services or your case manager. The Florida Division of Emergency Management can

also help you with your plan. You can call them at 1-850-413-9969 or visit their website

at www.floridadisaster.org

Tips on How to Prevent Medicaid Fraud and Abuse:

• DO NOT share personal information, including your Medicaid number, with

anyone other than your trusted providers.

• Be cautious of anyone offering you money, free or low-cost medical services, or

gifts in exchange for your Medicaid information.

• Be careful with door-to-door visits or calls you did not ask for.

• Be careful with links included in texts or emails you did not ask for, or on social

media platforms.

Fraud/Abuse/Overpayment in the Medicaid Program

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer

Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse

Complaint Form, which is available online at:

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

https://apps.ahca.myflorida.com/mpi-complaintform/

You can also report fraud and abuse to us directly by contacting Sunshine Health's

anonymous and confidential hotline at 1-866-685-8664 or by contacting the Compliance

Officer at 1-855-463-4100. You may also send an email to Compliancefl@centene.com.

Abuse/Neglect/Exploitation of People

Your child should never be treated badly. It is never okay for someone to hit your child

or make your child feel afraid. You can talk to your child’s PCP or case manager about

your child’s feelings.

If you feel that your child is being mistreated or neglected, you can call the Abuse

Hotline at 1-800-96-ABUSE (1-800-962-2873) or for TTY at 1- 800-955-8771.

You can also call the hotline if you know of someone else that is being mistreated.

Domestic Violence is also abuse. Here are some safety tips:

• If your child is hurt, call your PCP

• If your child needs emergency care, call 911 or go to the nearest hospital. For

more information, see the section called EMERGENCY CARE

• Have a plan to get to a safe place (a friend’s or relative’s home)

• Pack a small bag, give it to a friend to keep for you

If you have questions or need help, please call the National Domestic Violence Hotline

toll-free at 1-800-799-7233 (TTY 1-800-787-3224).

Advance Directives

An advance directive is a written or spoken statement about how you want medical

decisions made if you can’t make them yourself. Some people make advance directives

when they get very sick or are at the end of their lives. Other people make advance

directives when they are healthy. You can change your mind and these documents at

any time. We can help you get and understand these documents. They do not change

your child’s right to quality health care benefits. The only purpose is to let others know

what you want if you can’t speak for yourself.

1. A Living Will

2. Health Care Surrogate Designation

3. An Anatomical (organ or tissue) Donation

You can download an advance directive form from this website:

http://www.floridahealthfinder.gov/reports-guides/advance-directives.aspx.

Make sure that someone, like your child’s PCP, lawyer, family member, or case

manager knows that your child has an advance directive and where it is located.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

If there are any changes in the law about advance directives, we will let you know within

90 days. You don’t have to have an advance directive if you do not want one.

If your provider is not following your advance directive, you can file a complaint with

Member Services at 1-855-463-4100 or the Agency by calling 1-888-419-3456.

Getting More Information

You have a right to ask for information. Call Member Services or talk to your case

manager about what kinds of information you can receive for free. Some examples are:

• Your member record

• A description of how we operate

• Community programs

To take a look at Sunshine Health’s HEDIS results, please visit

https://www.sunshinehealth.com/members/medicaid/resources/quality-

improvement.html

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Section 19: Additional Resources

Floridahealthfinder.gov

The Agency is committed to its mission of providing “Better Health Care for All

Floridians.” The Agency has created a website www.FloridaHealthFinder.gov where you

can view information about Florida home health agencies, nursing facilities, assisted

living facilities, ambulatory surgery centers and hospitals. You can find the following

types of information on the website:

• Up-to-date licensure information

• Inspection reports

• Legal actions

• Health outcomes

• Pricing

• Performance measures

• Consumer education brochures

• Living wills

• Quality performance ratings, including member satisfaction survey results

The Agency collects information from all Plans on different performance measures

about the quality of care provided by the Plans. The measures allow the public to

understand how well Plans meet the needs of their members. To see the Plan report

cards, please visit http://www.floridahealthfinder.gov/HealthPlans/search.aspx. You may

choose to view the information by each Plan or all Plans at once.

Elder Housing Unit

The Elder Housing Unit provides information and technical assistance to elders and

community leaders about affordable housing and assisted living choices. The Florida

Department of Elder Affairs maintains a website for information about assisted living

facilities, adult family care homes, adult day care centers and nursing facilities at

http://elderaffairs.state.fl.us/doea/housing.php as well as links to additional Federal and

State resources.

MediKids Information

For information on MediKids coverage please visit:

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/program_policy/FLKidCar

e/MediKids.shtml

Aging and Disability Resource Center

You can also find additional information and assistance on State and federal benefits,

local programs and services, legal and crime prevention services, income planning or

educational opportunities by contacting the Aging and Disability Resource Center.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Independent Consumer Support Program

The Florida Department of Elder Affairs also offers an Independent Consumer Support

Program (ICSP). The ICSP works with the Statewide Long-Term Care Ombudsman

Program, the ADRC and the Agency to ensure that LTC members have many ways to

get information and help when needed. For more information, please call the Elder

Helpline at 1-800-96-ELDER (1-800-963-5337) or visit

http://elderaffairs.state.fl.us/doea/smmcltc.php.

Section 20: Forms

1. Appointment of a Designated Representative

2. Authorization and Revocation Form

3. Consent for Release of Medical Records

4. Notification of Pregnancy

5. Specialty Pharmacy Change Request Form

APPOINTMENT OF A DESIGNATED

REPRESENTATIVE

Case Number Customer’s Name

Completed by Customer Medicaid ID

I would like for

Name of Representative

to act on my behalf in determining

my eligibility for public assistance from the Department of Children and Families.

Signature of Customer Date

Completed by Representative

I understand that by accepting this appointment, I am responsible to provide or assist in

providing information needed to establish this person’s eligibility for assistance. I

understand that I may be prosecuted for perjury and/or fraud if I withhold information or

intentionally provide false information.

Signature of Representative Date

Relationship to Customer Street Address

City State

Phone Number

Self-Appointment by Representative

I am acting for in providing information to

establish eligibility for assistance because he/she is unable to act on his/her own behalf. I will

provide information to the best of my knowledge. I understand that if I withhold information or if I

intentionally provide false information, I may be prosecuted for perjury and/or fraud. I agree to

immediately report any change in their situation of which I become aware.

Signature of Representative Date

Relationship to Customer Street Address

City State

Phone Number

CF-AA 2505, PDF 03/2008 CNC Rev.01/11/2017

v.8.1.2016

Mail to: Sunshine Health Attn: Privacy Officer,

P.O. Box 459089 Fort Lauderdale, FL 33345-9089

Phone: 1-855-463-4100 or TTY 1‐800‐955‐8770

Section I.

Member Name (print):

Member ID Number: Member Date of Birth: / /

Section II.

I give Sunshine Health consent to release my health information to the below listed person(s) or

group(s) for the reason(s) below (add additional names or groups on page 2):

Name (person or group):

Relationship to Member:

Address:

City: State: Zip: Phone: ( ) -

Section III.

Reason I want my health information released:

Authorization to Use and Disclose Health Information

Notice to Member:

•

Completing this form will allow Sunshine Health to (i) use your health information for a particular

purpose, and/or (ii) share your health information with the individual or entity that you identify on this

form.

•

You do not have to sign this form or give permission to use or share your health information. Your

services and benefits with Sunshine Health will not change if you do not sign this form.

•

Right to cancel (revoke): This authorization/consent form is subject to revocation at any time except

to the extent that Sunshine Health or other lawful holder of your health information that is permitted

to share it has already acted in reliance on it. If you want to cancel this Authorization Form, fill out

the Revocation Form on the last page and mail it to the address at the bottom of the page.

•

Sunshine Health cannot promise that the person or group you allow us to share your health

information with will not share it with someone else.

•

Keep a copy of all completed forms that you send to us. We can send you copies if you need them.

•

Fill in all the information on this form. When finished, mail it to the address at the bottom of the first

page.

Mail to: Sunshine Health Attn: Privacy Officer,

P.O. Box 459089 Fort Lauderdale, FL 33345-9089

Phone: 1-855-463-4100 or TTY 1-800-955-8770

Authorization to Use and Disclose Health Information

Section IV.

I approve Sunshine Health to use or share the health information below:

All of my health information;

All of my health information EXCEPT (check all boxes that apply):

Prescription drug/medication information

Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV)

information

Treatment for alcohol and/or substance abuse information

Behavioral health services

Other:

Section V.

Authorization End Date: / / (End date is required. If no end date is listed,

authorization will expire one year from the date of approval).

Section VI.

Member Signature: Date: / /

(Member or Legal Representative Sign Here)

If you are signing for the Member, describe your relationship below. If you are the Member’s

representative, describe this below and send us copies of those forms such as power of

attorney or order of guardianship.

Name: Relationship:

Mail to: Sunshine Health Attn: Privacy Officer,

P.O. Box 459089 Fort Lauderdale, FL 33345-9089

Phone: 1-855-463-4100 or TTY 1-800-955-8770

Authorization to Use and Disclose Health Information

Member Name (print):

Member ID Number: Member Date of Birth: / /

Additional Individual Person(s) or Group(s) to Receive Health Information

Name (person or group):

Relationship to Member:

Address:

City: State: Zip: Phone: ( ) -

Name (person or group):

Relationship to Member:

Address:

City: State: Zip: Phone: ( ) -

Name (person or group):

Relationship to Member:

Address:

City: State: Zip: Phone: ( ) -

Revoke Authorization to Use and/or Disclose Health Information

Member Name (print):

Member ID Number: Member Date of Birth: / /

I want to cancel, or revoke, the consent I gave to Sunshine Health to release my health information

to the following person(s) or group(s).

Name (person or group):

Relationship to Member:

Authorization Signed Date (if known): / /

I understand that my health information (including, where applicable, my substance use

disorder records) may have already been used or shared because of the permission I gave

before. I also understand that this cancellation only applies to the permission I gave to use

my health information for a particular purpose or to share my health information with the

person or group. It does not cancel any other authorization forms I signed for health

information to be used for another purpose or shared with another person or group.

Member Signature:

(Member or Legal Representative Sign Here)

Date: / / _

If you are signing for the Member, describe your relationship below. If you are the Member’s personal

representative, describe this below and send us copies of those forms such as power of attorney or

order of guardianship.

Relationship:

Sunshine Health will stop using or sharing your health information when we receive and process this

form. Use the mailing address below. You can also call for help at the number below.

Mail to: Sunshine Health Attn: Privacy Officer,

P.O. Box 459089 Fort Lauderdale, FL 33345-9089

Phone: 1-855-463-4100 or TTY 1-800-955-8770

Consent for Release of Medical Records

I authorize __________________________________ to release copies of my medical records to:

(Provider/Office Name and Address)

A. I authorize release of information for: (refer to

Sections C and D)

Medical Care (physician, etc.)

_ Personal Care

Other: ❑Attorney ❑Insurance ❑Employer

or describe:

B. I am transferring from Medical Office #: To:

Medical Records for the specific treatment dates from to

D. I authorize rele

ase of the following portions of my

medical record: (Write your initials beside each area to

be included in the release)

Mental Health Substance Abuse

HIV/AIDS Communicable

Disease

Member ID:

Patient Name: Social Security # ______________________

Patient Address: ________________________________________________________________________

Date of Birth: Telephone Number:

C. I authorize release of

Entire medical record OR

I understand that this authorization shall be in effect for 1 year following the date of signature.

However, I understand that this authorization may be revoked at any time by giving oral or written

notice to the medical office. A photocopy of this authorization shall constitute a valid authorization. I

understand that once my records have been released, the medical office cannot retrieve them and has

no control over the use of the already released copies.

I hereby release Sunshine State Health Plan, its subsidiaries and affiliates, and my medical office from

any and all liability that may arise as a result of my authorized release of these records.

Should my case require review by a government agency or another medical professional actively

involved in my care to make a final determination, it is with my consent that a copy of these records

will be submitted to the agency or medical professional for this review.

PATIENT SIGNATURE OR LEGAL REPRESENTATIVE SIGNATURE DATE

RELATIONSHIP TO PATIENT WITNESS

NOTICE TO PROVIDER: The information disclosed to you originates from records whose confidentiality is

protected by Federal and State Law. You are prohibited from making further disclosure of such information

without the specific and documented approval of the person to whom the released information pertains, or

as otherwise permitted under State Law. A general authorization is NOT sufficient for this purpose.

Ver2 (03/2014)

CNC Rev. 01/11/2017

This form is confidential. If you have any problems or questions, please call Sunshine Health at 1-855-463-4100

(TTY: 1-800-955-8770). This form is also available online at SunshineHealth.com.

*Required Field

*Are You Pregnant?

Yes No * If you are pregnant, please continue to answer all the questions.

Return the form in the envelope provided. When your answers are received, a gift will be mailed to you!

We may call you if we ﬁnd that you are at risk for problems with your pregnancy.

*Medicaid ID #: Today’s Date MMDDYYYY:

Your First Name:

Your Last Name:

*Your Birth Date MMDDYYYY:

Mailing Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Would you like to receive text messages about pregnancy and newborn care? Yes No

If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.

Please note, texting is not secure and may be seen by others.

Email Address:

*Your OB Provider’s Name:

*Your Due Date MMDDYYYY:

Primary insurance (for mom or baby) other than Medicaid? Yes No

Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina

American Indian/Native American Asian Hawaiian/Paciﬁc Islander

Other If other ethnicity, please specify:

Preferred Language (if other than English):

Pediatrician chosen? Yes No Pediatrician Name:

Number of Full Term Deliveries: Number of Miscarriages:

Number of Preterm Deliveries: Number of Stillbirths:

Planning to breastfeed? Yes No If no, what is the reason?

Rev. 04 24 2018

FL-MNOP-2008

Member Notiﬁcation of Pregnancy

*2008*

Height (Feet, Inches):

Pre-Pregnancy Weight:

Your Medical History

*Do you have any of the following? Yes No If yes, mark all that apply.

Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No

Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No

Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No

Do you have enough food? Yes No Are you enrolled in WIC? Yes

Are you homeless or living in a shelter? Yes No

Do you have reliable phone access? Yes NoDo you have problems getting to your doctor visits? Yes No

Are you currently experiencing domestic violence or feel unsafe in your home? Yes No

Please list any other social needs you may have:

Please list anything else you would like to tell us about your health:

Previous neonatal death or stillbirth?High blood pressure (prior to pregnancy)? Yes No Yes No

Testing refused? Yes No AIDS? Yes NoHIV Negative? Yes NoHIV Positive? Yes No

Seizure Disorder?

Yes No Seizure within the last 6 months? Yes No

Previous alcohol or drug abuse? Yes No

*Medicaid ID #:

Name: Last, First:

Current Pregnancy History

Preterm labor this pregnancy? Yes No Current gestational diabetes? Yes No

Current twins? Current triplets?Yes No Yes No

Currently having severe morning sickness? Yes No

List:Current mental health concerns? Yes

List:Current STD? Yes No

Amount:Current tobacco use? Yes

If yes, are you interested in quitting?

Yes

Amount:Current alcohol use? Yes No

Current street drug use? Yes No

Taking any prescription drugs (other than prenatal vitamins)? List:Yes No

Any hospital stays this pregnancy?

Yes No

*2009*

Rev. 04 24 2018

Sickle Cell? Yes No

Asthma? Yes No If yes, are asthma symptoms worse during pregnancy? Yes No

Thyroid Problems? Yes No If yes, is this a new thyroid problem? Yes No

If yes, please list hospitalizations during this pregnancy.

Social Issues

If your answers indicate you are at an increased risk for complications during this pregnancy, would you consent to

participate in our Start Smart Case Management program to help you and your baby?

Yes No

1-855-463-4100

TDD/TTY 1-800-955-8770

SunshineHealth.com

Specialty Pharmacy Change Request Form

Pick a choice below. Please check the box next to the number.

Next, sign the form and mail or fax to:

Sunshine Health

P.O. Box 459089

Fort Lauderdale, FL 33345-9089

Fax: 1-866-351-7388

I wish to use the pharmacy listed below. I understand that if this pharmacy does not carry

my drug, a Sunshine Health Pharmacy staff member will call me to discuss other choices.

□

CVS Caremark Specialty Pharmacy

□

Accredo Health

□

Avella Specialty Pharmacy

□

Bioscrip Infusion Services

□

BioPlus Specialty Pharmacy

□

Diplomat Specialty Pharmacy

□

CVS Retail Pharmacy

Phone number: NPI Number (if available):

Address:

I wish to use the pharmacy listed above because:

□

They provide education and support not available at AcariaHealth

□

I can't accept home delivery

□

I can't accept doctor's office delivery

□

OTHER

Reason (for any of above):

Quest

ions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Alternative Formats Available

The information in this booklet is about your Sunshine

Health benefits. Alternative formats are available to you free

of charge.

Sunshine Health offers alternative formats such as:

• Large Print

• Audio

• Accessible electronic formats

• Information written in other languages

If you need this booklet in an alternative format, or for

another program such as Long-term Care, please call

Member Services for help at 1-855-463-4100 or TTY 1-800-

955-8770.

Formatos alternativos disponibles

La información de este cuadernillo trata sobre sus

beneficios de Sunshine Health. Hay formatos disponibles

para usted en forma gratuita.

Sunshine Health ofrece formatos alternativos, como:

• Letra grande

• Audio

• Formatos electrónicos accesibles

• Información escrita en otros idiomas

Si necesita este cuadernillo en formatos alternativos, por

favor, llame a Servicios para Miembros para pedir ayuda al

1-855-463-4100 o TTY 1-800-955-8770.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Disponible sur medias substituts

Les informations contenues dans cette brochure portent sur

les prestations de santé offertes par Sunshine Health. Les

publications vous sont offertes gratuitement en medias

substituts.

Sunshine Health offre les medias substituts tels que:

• Grand format

• Audio

• Supports électroniques accessibles

• Information disponibles dans d’autres langues.

Si vous avez besoin de cette brochure dans un format autre

que celui qui est offert, bien vouloir demander de l’aide au

Service aux membres en appelant le 1-855-463-4100 ou

TTY 1-800-955-8770.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Fòma Altènatif Disponib

Enfòmasyon nan livre sa a konsène benefis ou yo nan

Sunshine Health. Gen lòt fòma altènatif ki disponib pou w

gratis tou.

Sunshine Health ofri kèk fòma altènatif tankou :

• Gwo Karaktè

• Odyo

• Fòma Elektwonik ki Aksesib

• Enfòmasyon ki ekri nan lòt lang

Si w bezwen livre sa a nan yon lòt fòma, souple rele Sèvis

Manm yo pou èd nan 1-855-463-4100 oswa nan ATS

(aparèy telekominikasyon pou moun ki soud) 1-800-955-

8770.

Formati alternativi disponibili

Le informazioni contenute in questo opuscolo riguardano i

benefici della Sushine Health.

La Sunshine Health offre formati alternativi come:

• Stampa a caratteri grandi

• Formato audio

• Formati elettronici accessibili

• Informazioni scritte in altre lingue

In caso si necessiti di questo opuscolo in altri formati, è

necessario chiamare l’assistenza clienti al 1-855-463-4100

TTY al 1-800-955-8770.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Доступны альтернативные форматы

Информация в этом буклете касается медицинских

льгот, предоставляемых вам компанией Sunshine

Health. Вы можете бесплатно получить буклеты в

альтернативных форматах.

Sunshine Health предоставляет документы в

альтернативных форматах, в частности:

• Написанные крупным шрифтом

• В аудиоформате

• В электронном виде с расширенным доступом

• Содержащие информацию на других языках

Если вам необходимо получить данный буклет в

альтернативном формате, просим обратиться за

помощью в отдел обслуживания клиентов по телефону

1-855-463-4100 или TTY 1-800-955-8770.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

Statement of Non-Discrimination

Sunshine Health complies with applicable Federal civil rights laws and does not

discriminate on the basis of race, color, national origin, age, disability, or sex. Sunshine

Health does not exclude people or treat them differently because of race, color, national

origin, age,

disability, or sex.

Sunshine Health:

Provides free aids and services to people with disabilities to communicate effectively with

us,

such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic

formats, other

formats)

Provides free language services to people whose primary language is not English, such

as:

• Qualified interpreters

• Information written in other languages

If you need these services, contact Sunshine Health at 1-855-463-4100 (Relay FL 1-800-

955-8770).

If you believe that Sunshine Health has failed to provide these services or discriminated

another way on the basis of race, color, national origin, age, disability, or sex, you can

file a grievance

with: Grievance/Appeals Unit Sunshine Health, P.O. Box 459087, Fort

Lauderdale, FL 33345-9087, 1-855-463-4100 (Relay Florida 1-800-955-8770), Fax, 1-

866-534-5972. You can file a grievance

in person or by mail, fax, or email. If you need

help filing a grievance, Sunshine Health is

available to help you. You can also file a civil

rights complaint with the U.S. Department of Health and

Human Services, Office for

Civil Rights electronically through the Office for Civil Rights Complaint Portal,

available

at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department

Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH

Building, Washington,

DC 20201, 1-800-368-1019, 800-537-7697 (TTY).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

This information is available for free in other languages.

Please contact our customer service number at 1-855-

463-4100, TTY 1-800-955-8770 Monday through Friday,

8 a.m. to 8 p.m.

Esta información está disponible en otros idiomas de

manera gratuita. Comuníquese con nuestro número de

servicio al cliente al 1-855-463-4100, TTY 1-800-955-8770

de lunes a viernes, de 8 a.m. a 8 p.m.

Questions? Call Member Services at 1-855-463-4100 or 1-800-955-8770 TTY

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