Fillable MMA LTC Member Handbook (Sunshine Health)

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MMA LTC Member Handbook (Sunshine Health)

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October 2020
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
2
“If you do not speak English, call us at 1-866-796-0530. 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 1-866-796-0530. 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 1-866-796-0530. 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 1-866-796-0530. 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 1-866-796-0530. 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 1-866-796-0530. 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 1-866-796-0530 or TTY at 1-800-955-8770
3
Important Contact Information
Member Helpline
1-866-796-0530
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
LogistiCare
(Transportation)
HearUSA
(Hearing Services)
Envolve Pharmacy
Solutions
(Pharmacy Services)
Florida Care Management
Services Agency
(Long-Term Care Case
Management
GT Independence
(Long-Term Care PDO)
Envolve PeopleCare
(Disease Management)
Envolve PeopleCare Nurse
Advice Line
Dental Services
1-866-796-0530 for help with arranging these
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
4
Important Contact Information
Service
To report suspected cases
of abuse, neglect,
abandonment, or
exploitation of children or
vulnerable adults
TTY: 711 or 1-800-955-8771
http://www.myflfamilies.com/service-
programs/abuse-hotline
For Medicaid Eligibility
TTY: 711 or 1-800-955-8771
http://www.myflfamilies.com/service-
programs/access-florida-food-medical-assistance-
To report Medicaid Fraud
and/or Abuse
https://apps.ahca.myflorida.com/mpi-
To file a complaint about a
health care facility
http://ahca.myflorida.com/MCHQ/Field_Ops/CAU.s
To request a Medicaid Fair
Hearing
1-239-338-2642 (fax)
To file a complaint about
Medicaid services
TTY: 1-866-467-4970
To find information for
elders
To find out information
about domestic violence
TTY: 1-800-787-3224
http://www.thehotline.org/
To find information about
health facilities in Florida
To find information about
urgent care
For an emergency
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
5
Table of Contents
Section 1: Your Plan Identification Card (ID card)....................... Page 9
Section 2: Your Privacy ............................................................... Page 11
Section 3: Getting Help from Member Services ........................ Page 16
Contacting Member Services .................................................. Page 16
Contacting Member Services after Hours ................................ Page 16
Section 4: Do You Need Help Communicating? ........................ Page 16
Section 5: When Your Information Changes ............................. Page 17
Section 6: Your Medicaid Eligibility ............................................ Page 17
If You Lose Your Medicaid Eligibility ....................................... Page 17
If You Have Medicare .............................................................. Page 17
If You Are Having a Baby ........................................................ Page 17
Section 7: Enrollment in Our Plan .............................................. Page 19
Open Enrollment ..................................................................... Page 19
Enrollment in the SMMC Long-Term Care Program ................ Page 19
Section 8: Leaving Our Plan (Disenrollment) ............................ Page 21
Removal from Our Plan (Involuntary Disenrollment) ............... Page 21
Section 9: Managing Your Care .................................................. Page 22
Changing Case Managers ....................................................... Page 22
Important Things to Tell Your Case Manager .......................... Page 22
Section 10: Accessing Services ................................................. Page 23
Providers in Our Plan .............................................................. Page 23
Providers Not in Our Plan ........................................................ Page 23
Dental Services ....................................................................... Page 24
What Do I Have To Pay For? .................................................. Page 24
Services for Children ............................................................... Page 24
Moral or Religious Objections .................................................. Page 25
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
6
Section 11: Helpful Information About Your Benefits ............... Page 25
Choosing a Primary Care Provider (PCP) ............................... Page 25
Choosing a PCP for Your Child ............................................... Page 26
Specialist Care and Referrals .................................................. Page 26
Second Opinions ..................................................................... Page 26
Urgent Care ............................................................................. Page 27
Hospital Care ........................................................................... Page 27
Emergency Care ..................................................................... Page 27
Provider Standards for PCP and
Specialist Appointment Scheduling ......................................... Page 28
Filling Prescriptions ................................................................. Page 29
Specialty Pharmacy Information .............................................. Page 29
Behavioral Health Services ..................................................... Page 30
Member Reward Programs ..................................................... Page 31
Disease Management Programs ............................................. Page 35
Advance Directives .................................................................. Page 36
Quality Enhancement Programs .............................................. Page 36
Well Child Visits ....................................................................... Page 37
Domestic Violence ................................................................... Page 37
Pregnancy Prevention ............................................................. Page 37
Pregnancy Related Programs ................................................. Page 38
Healthy Start Partnerships ....................................................... Page 38
Nutritional Assessment and Counseling .................................. Page 38
Behavioral Health .................................................................... Page 39
Section 12: Your Plan Benefits:
Managed Medical Assistance Services ...................................... Page 40
Your Plan Benefits: Expanded Benefits ................................... Page 59
Your Plan Benefits: Behavioral Health Enhanced Benefits...... Page 64
Section 13: Long-Term Care Program Helpful Information ...... Page 65
Starting Services ..................................................................... Page 65
Developing a Plan of Care....................................................... Page 65
Updating your Plan of Care ..................................................... Page 66
Your Back-Up Plan .................................................................. Page 67
Section 14: Your Plan Benefits: Long-Term Care Services ...... Page 67
Long-Term Care Participant Direction Option .......................... Page 73
Your Plan Benefits: LTC Expanded Benefits ........................... Page 74
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
7
Section 15: Member Satisfaction ................................................ Page 75
Complaints, Grievances and Plan Appeals ............................. Page 75
Fast Plan Appeal ..................................................................... Page 77
Medicaid Fair Hearings (for Medicaid Members) ..................... Page 77
Review by the State (for MediKids Members) ......................... Page 77
Continuation of Benefits for Medicaid Members ...................... Page 78
Section 16: Your Member Rights ................................................ Page 78
LTC Members have the right to: .............................................. Page 78
Section 17: Your Member Responsibilities ................................ Page 79
LTC Members have the responsibility to: ................................ Page 79
Section 18: Other Important Information ................................... Page 80
Patient Responsibility .............................................................. Page 80
Emergency Disaster Plan ........................................................ Page 81
Fraud/Abuse/Overpayment in the Medicaid Program .............. Page 81
Abuse/Neglect/Exploitation of People ..................................... Page 81
Advance Directives .................................................................. Page 82
Getting More Information ......................................................... Page 82
Section 19: Additional Resources .............................................. Page 83
Floridahealthfinder.gov ............................................................ Page 83
Elder Housing Unit .................................................................. Page 83
MediKids Information ............................................................... Page 83
Aging and Disability Resource Center ..................................... Page 84
Independent Consumer Support Program ............................... Page 84
Section 20: Forms ........................................................................ Page 84
Appointment of a Designated Representative ......................... Page 85
Authorization to Use and Disclose Health Information ............ Page 86
Revocation of Authorization to Use and/or Disclose
Health Information .................................................................. Page 89
Consent for Release of Medical Records ................................ Page 90
Member Notification of Pregnancy .......................................... Page 92
Specialty Pharmacy Change Request Form ............................ Page 94
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
8
Welcome to Sunshine Health’s
Statewide Medicaid Managed Care 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. You are
enrolled in our SMMC plan. This means that we will offer you Medicaid services. We
work with a group of health care providers to help meet your needs.
There are many types of Medicaid services that you can receive in the SMMC
program. You 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 you. You
can ask us any questions, or get help making appointments. If you need to speak
with us, just call us at 1-866-796-0530.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
9
Section 1: Your Plan Identification Card (ID card)
You should have received your ID card in the mail. Call us if you have not received
your card or if the information on your card is wrong. Each member of your family in
our plan should have their own ID card.
Carry your ID card at all times and show it each time you go to a health care
appointment. Never give your ID card to anyone else to use. If your card is lost or
stolen, call us so we can give you a new card.
Your Member ID card will look like this:
(Front)
(Back)
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
10
If you are a Long-Term Care member only, your Member ID card will look like this:
(Front)
(Back)
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
11
Section 2: Your Privacy
Your privacy is important to us. You have rights when it comes to protecting your
health information, such as your name, Plan identification number, race, ethnicity and
other things that identify you. We will not share any health information about you that
is not allowed by law.
If you have any questions, call Member Services. Our Sunshine Health Privacy
Practices describes how medical information about you 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, please call 1-866-796-0530.
Hearing impaired TTY 1-800-955-8770.
Si necesita ayuda para traducir o entender este texto, por favor llame al telefono.
1-866-796-0530. (TTY 1-800-955-8770).
Interpreter services are provided free of charge to you.
Covered Sunshine Health Duties:
At Sunshine Health, your privacy is important to us. We will do all we can to protect
your health records. By law, we must protect these health records.
Our Privacy Practices policy tells you how we use your health records. It describes
when we can share your records with others. It explains your rights about the use of
your health records. It also tells you how to use those rights and who can see your
health records. This does not apply to health records that do not identify you. 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 new notice.
Please note: You will also receive a Privacy Practice Notice from Medicaid outlining
its rules for your health records. Other health plans and health care providers may
have other rules when using or sharing your health records. We ask that you obtain a
copy of their Privacy Practices Notices and read them carefully.
How We Use or Share Your Health Records:
Below is a list of how we may use or share your health records without your consent:
• Treatment. We may use or share your health records with doctors or other
health care providers providing medical care to you and to help manage your
care. For example, if you are in the hospital, we may give the hospital your
records sent to us by your doctor.
• Payment. We may use and disclose your Personal Health Information (PHI)
to make benefit payments for the health care services provided to you. We
may release your PHI to another health plan, to a health care provider, or
other entity subject to the federal Privacy Rules for their payment purposes.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
12
• Health Care Operations. We may use and share your health records to:
perform our health care operations; help resolve any appeals or grievances
filed by you or a health care provider with Sunshine Health or the State of
Florida; or help assist others who help us provide your health services. We will
not share your records with these groups unless they agree to protect your
records.
• Appointment Reminders/Treatment Alternatives. We may use and release
your 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 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 health records.
• Public Health Activities. We may release your health records to a public
health authority to prevent or control disease, injury or disability. We may
release your 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 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 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 health records to law enforcement,
when required. For instance, a court order, court-ordered warrant, subpoena
or summons issued by a judicial officer, or a grand jury subpoena. We may
also release your health records to find or locate a suspect, fugitive or missing
person.
• Coroners, Medical Examiners and Funeral Directors. We may release your
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 health records
to funeral directors, as needed, to carry out their duties.
• Organ, Eye and Tissue Donation. We may release your 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 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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
13
• Specialized Government Functions. If you are a member of U.S. Armed
Forces, we may release your health records as required by military command
authorities. We may also release your health records to:
• authorized federal officials for national security
• 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 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 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 best interest. If it is in your best
interest, we will release only your health records that are directly relevant to
the person’s involvement in your care.
• Inmates. If you are an inmate of a correctional institution or under the custody
of a law enforcement official, we may release your PHI to the correctional
institution or law enforcement official where such information is necessary for
the institution to provide you with health care, to protect your 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 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 health
records.
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 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 health records for which payment may be made to
us.
• Marketing. We will request your written consent to use or release your 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 you promotional gifts of modest value.
• Psychotherapy Notes. We will request your written consent to use or share
any of your psychotherapy notes that we have on file with limited exception.
For instance, for certain treatment, payment or health care operation functions.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
14
All other uses and releases of your health records not described 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 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 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 notice. 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 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 you 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 health records in other ways or
locations. This right only applies if the information could harm you 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 you could be harmed if the change is
not made. We must work with your request if it is reasonable and states the
other way or place where your 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 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 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 health records we keep about you. 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
15
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 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 (6) years in which we or our
business associates released your 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 privacy rights have been violated,
or that we have violated our own privacy practices, you can file a complaint
with us in writing or by phone. Use the contact information at the end of this
notice. 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 Ave. 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 our 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.
Contact Information:
If you have any questions about our Privacy Practices related to your 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
16
Section 3: Getting Help from Member Services
Our Member Services department can answer all of your questions. We can help you
choose or change your 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 you or your family’s benefits.
Contacting Member Services
You may call us at 1-866-796-0530, or TTY at 1-
800-955-8770, Monday through Friday, 8 a.m. to 8
p.m., but not on state approved holidays (like
Christmas Day and Thanksgiving Day). When you
call, make sure you have your identification card
(ID card) with you so we can help you. (If you lose
your 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, you may call
our 24-hour Nurse Advice Line at 1-866-796-0530.
Our nurses are available to help you 24 hours a
day, seven days a week.
Section 4: Do You Need Help Communicating?
If you do not speak English, we can help. We have people who help us talk with
you in your language. We provide this help at no charge to you.
For people with disabilities: If you use 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 1-866-796-0530. 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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
17
Section 5: When Your Information Changes
If any of your 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
health care needs.
The Department of Children and Families (DCF) needs to know when your 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
Social Security account at https://secure.ssa.gov/RIL/SiView.do.
Section 6: Your Medicaid Eligibility
In order for you to go to your health care appointments and for Sunshine Health to
pay for your services, you have to be covered by Medicaid and enrolled in our plan.
This is called having Medicaid eligibility. DCF decides if someone qualifies for
Medicaid.
Sometimes things in your life might change, and these changes can affect whether or
not you can still have Medicaid. It is very important to make sure that you have
Medicaid before you go to any appointments. Just because you have a Plan ID card
does not mean that you still have Medicaid. Do not worry! If you think your Medicaid
has changed or if you have any questions about your Medicaid, call Member
Services and we can help you check on it.
If You Lose Your Medicaid Eligibility
If you lose your Medicaid eligibility and get it back within 180 days, you will be
enrolled back into our plan.
If You Have Medicare
If you have Medicare, continue to use your Medicare ID card when you need medical
services (like going to the doctor or the hospital), but also give the provider your
Medicaid Plan ID card too.
If You Are Having a Baby
If you have a baby, he or she will be covered by us on the date of birth. Call Member
Services to let us know that your baby has arrived and we will help make sure your
baby is covered and has Medicaid right away.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
18
It is helpful if you let us know that you are pregnant before your baby is born to make
sure that your baby has Medicaid. Call DCF toll free at 1-866-762-2237 while you are
pregnant. If you need help talking with DCF, call us. DCF will make sure your baby
has Medicaid from the day he or she is born. They will give you a Medicaid number
for your baby. Let us know the baby’s Medicaid number when you get it.
Please let us know you are pregnant right away so that we can help you get all
needed prenatal care to protect your health and your baby’s. You can do this by
calling Member Services. A representative can help you fill out a Notice of Pregnancy
Form. You can also find this form in Section 20 of this Handbook.
If you are
pregnant,
let us know
right away.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
19
Section 7: Enrollment in Our Plan
When you first join 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, you are 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 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 you live in a Medicaid
nursing facility full time, you are probably already in the LTC program. If you don’t
know, or don’t think you are 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 you can receive these services, you
have to speak with someone who will ask you questions about your 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
name will go on a wait list. When you get 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 yourself to
make sure you meet other medical criteria to receive services from the LTC program.
Once you are enrolled in the LTC program, we will make sure you continue to meet
requirements for the program each year.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
20
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 1-866-796-0530 or TTY at 1-800-955-8770
21
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 with 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
1
):
• You are 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
• You are an American Indian or Alaskan Native
• You live in and get your 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
2
:
• You receive poor quality of care, and the Agency agrees with you after they
have looked at your medical records
• You cannot get the services you need through our plan, but you can get the
services you need through another plan
• Your 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).
Removal from Our Plan (Involuntary Disenrollment)
The Agency can remove you from our plan (and sometimes the SMMC program
entirely) for certain reasons. This is called involuntary disenrollment. These
reasons include:
• You lose your Medicaid
• You move outside of where we operate, or outside the State of Florida
• You knowingly use your Plan ID card incorrectly or let someone else use your
Plan ID card
1
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%20CARE&ID=59G-8.600
2
To learn how to ask for an appeal, please turn to Section 15, Member Satisfaction,
on Page 73.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
22
• You fake or forge prescriptions
• You or your caregivers behave in a way that makes it hard for us to provide
you with care
• You are in the LTC program and live in an assisted living facility or adult family
care home that is not home-like and you will not move into a facility that is
home-like
3
If the Agency removes you 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 you have 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 you need. The case manager will work with your other
providers to manage your health care. If we provide you with a case manager and
you do not want one, call Member Services to let us know.
If you are in the LTC program, we will assign you a case manager. You must have a
case manager if you are in the LTC program. Your case manager is your go-to
person and is responsible for coordinating your care. This means that they are the
person who will help you figure out what LTC services you need and how to get
them.
If you have a problem with your care, or something in your life changes, let your case
manager know and they will help you decide if your services need to change to better
support you.
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 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 services aren’t right
• You get new health insurance
• You go to the hospital or emergency room
• Your caregiver can’t help you anymore
3
This is for Long-Term Care program members only. If you have questions about you facility’s
compliance with this federal requirement, please call Member Services or your case manager.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
23
• Your living situation changes
• Your 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 you get a service or go to a health care appointment, we have to make sure
that you need the service and that it is medically right for you. This is called prior
authorization. To do this, we look at your medical history and information from your
doctor or other health care providers. Then we will decide if that service can help you.
We use rules from the Agency to make these decisions.
Providers in Our Plan
For the most part, you 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 you use 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 1-866-796-0530 to get a copy or visit our
website at SunshineHealth.com.
If you are in the LTC program, your case manager is the person who will help you
choose a service provider for each of your services. Once you choose a service
provider, they will contact them to begin your services. This is how services are
approved in the LTC program. Your case manager will work with you, your family,
your caregivers, your doctors and other providers to make sure that your LTC
services work with your medical care and other parts of your life.
Providers Not in Our Plan
There are some services that you can get from providers who are not in our provider
network. These services are:
• Family planning services and supplies
• Women’s preventative 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
24
before you use a provider that is not in our provider network. If you have questions,
call Member Services.
Dental Services
Your dental plan will cover most of your 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 dentist or
dental hygienist
Covered when you see
your doctor or nurse
Scheduled dental
services in a hospital or
surgery center
Covered for dental
services by your
dentist
Covered for doctors,
nurses, hospitals and
surgery centers
Hospital visit for a dental
problem
Not covered
Covered
Prescription drugs for a
dental visit or problem
Not covered
Covered
Transportation to your
dental service or
appointment
Not covered
Covered
Contact Member Services at 1-866-796-0530 (TTY: 1-800-955-8770).
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 you 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
4
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
• No time limits, like hourly or daily limits
4
Also known as “Early and Periodic Screening, Diagnosis and Treatment” or “EPSDT” requirements.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
25
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:
http://ahca.myflorida.com/Medicaid/Policy_and_Quality/Policy/Covered_Services_HC
BS_Waivers.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.
Section 11: Helpful Information About Your Benefits
Choosing a Primary Care Provider (PCP)
If you have Medicare, please contact the number on your Medicare ID card for
information about your 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.
If you have Medicaid or MediKids but you do not have Medicare, one of the first
things you will need to do when you enroll in our plan is choose a PCP. This can be a
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
26
doctor, nurse practitioner, or a physician assistant. You will see your PCP for regular
check-ups, shots (immunizations), or when you are sick. Your PCP will also help you
get care from other providers or specialists. This is called a referral. You can choose
your 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 you and
your family.
You can change your PCP at any time. To change your PCP, call Member Services.
Choosing a PCP for Your Child
You can pick a PCP for your baby before your baby is born. We can help you with
this by calling Member Services. If you do not pick a PCP by the time your baby is
born, we will pick one for you. If you want to change your baby’s PCP, call us.
It is important that you select a PCP for your child 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 and your child’s PCP know what is going on with
your child and how they are growing. Your child may also receive shots
(immunizations) at these visits. These visits can help find problems and keep your
child healthy.
5
You can take your 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, you may need to see a provider other than your PCP for medical
problems like special conditions, injuries or illnesses. Talk to your PCP first. Your
PCP will refer you to a specialist. A specialist is a provider who works in one health
care area.
If you have a case manager, make sure you tell your case manager about your
referrals. The case manager will work with the specialist to get you care.
Second Opinions
You have the right to get a second opinion about your care. This means talking with
a different provider to see what they have to say about your care. The second
provider will give you their point of view. This may help you decide if certain services
or treatments are best for you. There is no cost to you to get a second opinion.
5
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 1-866-796-0530 or TTY at 1-800-955-8770
27
Your 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
you need to see a provider that is not in our provider network for the second opinion,
we must approve it before you see them.
Urgent Care
Urgent Care is not Emergency Care. Urgent Care is needed when you have an injury
or illness that must be treated within 48 hours. Your health or life is not usually in
danger, but you cannot wait to see your PCP or it is after your PCP’s office has
closed.
If you need Urgent Care after office hours and you cannot reach your PCP, call our
24-hour Nurse Advice Line at 1-866-796-0530. You will be connected to a nurse.
Have your 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 PCP.
You may also find the closest Urgent Care center to you by calling Member Services
at 1-866-796-0530 or visiting our website at SunshineHealth.com and clicking “Find a
Provider.”
Hospital Care
If you need to go to the hospital for an appointment, surgery or overnight stay, your
PCP will set it up. We must approve services in the hospital before you go, except for
emergencies. We will not pay for hospital services unless we approve them ahead of
time or it is an emergency.
If you have a case manager, they will work with you and your provider to put services
in place when you go home from the hospital.
Emergency Care
You have a medical emergency when you are so sick or hurt that your life or health
is in danger if you do not get medical help right away. Some examples are:
• Broken bones
• Bleeding that will not stop
• You are pregnant, in labor and/or bleeding
• Trouble breathing
• Suddenly unable to see, move or talk
Emergency services are those services that you get when you are very ill or injured.
These services try to keep you alive or to keep you from getting worse. They are
usually delivered in an emergency room.
If your condition is severe, call 911 or go to the closest emergency facility right
away. You can go to any hospital or emergency facility. If you are not sure if it is
an emergency, call your PCP. Your PCP will tell you what to do.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
28
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 you receive in an emergency room to treat your condition.
If you have an emergency when you are away from home, get the medical care you
need. Be sure to call Member Services when you are able and let us know.
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
receiving service that is answered
by a live person.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
29
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 prescription is filled.
We have pharmacies in our provider network. You can fill your prescription at any
pharmacy that is in our provider network. Make sure to bring your 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 1-866-796-0530.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
30
Behavioral Health Services
There are times when you may need to speak to a therapist or counselor, for
example, if you are having any of the following feelings or problems:
• Always feeling sad
• Not wanting to do the things that you used to enjoy
• Feeling worthless
• Having trouble sleeping
• Not feeling like eating
• Alcohol or drug abuse
• Trouble in your marriage
• Parenting concerns
We cover many different types of behavioral health services that can help with issues
you may be facing. You can call a behavioral health provider for an appointment. You
can get help finding a behavioral health provider by:
• Calling 1-866-796-0530
• 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 PCP for behavioral health services.
If you are thinking about hurting yourself or someone else, call 911. You can
also go to the nearest emergency room or crisis stabilization center, even if it is out of
our service area. Once you are in a safe place, call your PCP if you can. Follow up
with your provider within 24-48 hours. If you get emergency care outside of the
service area, we will make plans to transfer you to a hospital or provider that is in our
plan’s network once you are stable.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
31
Member Reward Programs
We offer programs to help keep you healthy and to help you live a healthier life (like
losing weight or quitting smoking). We call these healthy behavior programs. You
can earn rewards while participating in these programs. Our plan offers the following
programs:
Reward
Reward Value
Limitations
Well Child Visits in First
15 Months
$50
• Ages birth 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.
Preventive Adult Primary Care
Visit
$10
• Age 21 and older.
• Visit must be with
PCP.
• Only one reward for
this service per
calendar year.
Cervical Cancer Screening
$10
• Females ages 21 to
64.
• Only one reward for
this service per
calendar year.
Breast Cancer Screening
$10
• Females ages
50 to 74.
• 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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
32
Reward
Reward Value
Limitations
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 Visits
$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.
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 post discharge
visit must occur within
seven calendar days
after the date of the
discharge.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
33
Reward
Reward Value
Limitations
Substance Abuse Health
Coaching and/or Treatment
Up to $30
• Ages 12 and older.
• Reward for up to three
coaching sessions
with a case manager.
The third session must
occur within three
months of the date of
the first session.
• Reward for a visit with
a substance abuse
provider for any of the
three 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 Sunshine
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 1-866-796-0530 or TTY at 1-800-955-8770
34
Reward
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
$5
• Consent form must be
signed and received at
Health Plan.
• Up to two program
consents per calendar
year: one for Tobacco
Cessation and one for
Weight Loss.
New Member Health Risk
Screening
Sunshine Health wants to know
how we can better serve you.
One way we do this is by
asking you to fill out a Health
Risk Screening. This form gives
us information to determine
your needs. You can locate the
form inside our secure member
portal:
www.sunshinehealth.com/login.
$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 you make certain healthy choices,
reward dollars will automatically be put on your rewards card. The rewards are added
approximately two weeks after we receive the claim from your provider for the healthy
behavior you’ve completed. If it’s your first reward, a card will be mailed to you.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
35
Please remember that rewards cannot be transferred. If you leave our plan for more
than 180 days, you may not receive your reward. If you have questions or want to
join any of these programs, please call us at 1-866-796-0530, or visit
SunshineHealth.com.
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 you to see a doctor. It means helping you understand and
manage your health conditions. We do this through our disease management
programs. Members are provided education and personal help from Sunshine Health
staff. The goal of this service is to add to the quality of your care and help you to
improve your health.
If you have one of the conditions below, call Member Services for information:
• Asthma
• Cancer
• Chronic Obstructive
Pulmonary Disease
(COPD)
• Depression
• Diabetes
• Heart Failure
• HIV/AIDS
• Hypertension
• Substance Abuse
Disorder
All of our programs are geared toward helping you understand and actively manage
your health. We are here to help you with things like:
• How to take medicines
• What screening tests to get
• When to call your doctor
• When to go to the Emergency Room
We will help you get the
things you need. We will
provide tools to help you
learn and take control of
your condition. For more
information, call Member
Services at
1-866-796-0530, and ask
to speak with a case
manager.
If you are in the LTC
program, we also offer
programs for Dementia
and Alzheimer’s issues.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
36
Sunshine Health’s Alzheimer’s & Dementia program focuses on LTC members
diagnosed with these conditions. We will work with you to create a person-centered
care plan that includes goals and interventions to address your needs.
This program is based on personal care planning and a cohesive team approach. It
provides education and resources to promote member choice and improve your
understanding of services and supports available to you.
Advance Directives
Advance Directives are written instructions about the health care you want to receive
if you are unable to speak for yourself. 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 you need it.
You can call Member Services if you have questions or to ask for a copy of our
policy. The number is 1-866-796-0530, or talk with your PCP if you have any
questions. Call them if you need help in finding the form. Once finished, ask your
PCP to put the form in your file. You can make changes to your directive when you
want to. If the law changes, we will let you know within 90 days of any change.
If your directive is not being followed, you can call the state’s complaint line at 1-888-
419-3456.
Together, you and your PCP can make decisions that will set your mind at ease. It
can help your doctors understand your wishes about your health. Advance Directives
will not take away your right to make your own decisions. They will work only when
you are unable to speak for yourself. You 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 described on the following pages.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
37
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.
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 1-866-796-0530.
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.
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 1-866-796-0530 or TTY at 1-800-955-8770
38
Pregnancy Related Programs
Start Smart for Your Baby (Start Smart) is our special program for women who are
pregnant. Sunshine Health wants to help you take care of yourself and your baby
through your whole pregnancy. Information can be provided to you by mail,
telephone and at SunshineHealth.com/members/medicaid/benefits-
services/pregnancy-and-newborn-services.html. Our Start Smart staff can answer
questions and give you support if you are having a problem. We can even arrange for
a home visit if needed.
If you are pregnant and smoke cigarettes, Sunshine Health can help you stop
smoking. We have a special stop smoking program for pregnant women. There is no
cost to you. The program has trained staff who are ready to work with you. They will
provide education, counseling and the support you need to help you quit smoking.
Working as a team over the telephone, you and your health coach can make a plan
to make changes in your behavior and lifestyle. These coaches will encourage and
help you to stop smoking.
We have many ways to help you have a healthy pregnancy. Before we can help, we
need to know you are pregnant. Please call Member Services at 1-866-796-0530 as
soon as you learn you are pregnant. We will help you set up the special care that you
and your baby need. Sunshine Health does not restrict services including counseling
or referrals for moral or religious objections.
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
39
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 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 1-866-796-0530.
Case managers
can help find
community
resources.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
40
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, you may need a referral from your 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
6
.
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.
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.
6
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 1-866-796-0530 or TTY at 1-800-955-8770
41
Except for emergency care, Sunshine Health must prior authorize any services
provided by an out-of-network provider 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.
No
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.
No
Ambulatory
Detoxification
Services
Substance
abuse
treatment of
detoxification
services
provided in an
outpatient
setting.
For members under
age 21: Up to three
hours per day and
no limit per calendar
year.
For members over
age 21: Up to three
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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
42
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) that
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
Behavioral
health 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
43
Service
Description
Coverage/
Limitations
Prior
Authorization
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.
Child must be
enrolled in the DOH
Early Steps
program.
No
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.
No
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.
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
44
Service
Description
Coverage/
Limitations
Prior
Authorization
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.
Ages 0 to 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.
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.
No
Drop-In
Center
Services
A social club
offering peer
support and a
flexible
schedule of
activities.
18 years of age and
older.
Maximum of 20 days
per calendar year.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
45
Service
Description
Coverage/
Limitations
Prior
Authorization
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 1-866-796-0530
(TTY: 1-800-955-
8770) for more
information.
Prior authorization may
be required for some
equipment or services.
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 three
screenings per
calendar year.
- Up to three
follow-up
evaluations per
calendar year.
- Up to two
training or
support sessions
per week.
No
Emergency
Transportation Services
Transportation
provided by
ambulances or
air ambulances
(helicopter or
airplane) to get
you to a hospital
because of an
emergency.
Covered as
medically
necessary.
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
46
Service
Description
Coverage/
Limitations
Prior
Authorization
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.
No
Family Therapy
Services
Services for
families to have
therapy
sessions with a
mental health
professional.
We cover:
- Up to 26 hours
per calendar
year.
Yes, after
12 sessions.
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
47
Service
Description
Coverage/
Limitations
Prior
Authorization
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 three
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 four visits
per day for
pregnant
members and
members ages
0-20.
- Up to three visits
per day for all
other members.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
48
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.
Ages 0-5 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
49
Service
Description
Coverage/
Limitations
Prior
Authorization
Integumentary
Services
Services to
diagnose or treat
skin conditions,
illnesses or
diseases.
Covered as
medically
necessary.
Yes, for some services.
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.
No
Medication
Assisted
Treatment
Services
Services used to
help people who
are struggling with
drug addiction.
Covered as
medically
necessary.
No
Medication
Management
Services
Services to help
people
understand and
make the best
choices for taking
medication.
Covered as
medically
necessary.
No
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
Emergency
mental health
services provided
in the home,
community or
school by a team
of health care
professionals.
All ages.
96 units per
calendar year.
- Maximum of 8
units per day
(1 unit = 15
minutes).
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
50
Service
Description
Coverage/
Limitations
Prior
Authorization
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.
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 members 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
51
Service
Description
Coverage/
Limitations
Prior
Authorization
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 0-20
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
five years.
We cover for people
of all ages:
- Follow-up
wheelchair
evaluations, one
at delivery and
one six months
later.
Yes, for some services.
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
52
Service
Description
Coverage/
Limitations
Prior
Authorization
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 four-
six hours each day
for five days per
week.
All ages.
One per day and no
limit per calendar
year.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
53
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
54
Service
Description
Coverage/
Limitations
Prior
Authorization
Private Duty
Nursing Services
Nursing services
provided in the
home to members
ages 0 to 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
Psychosocial
Rehabilitation
Services
Services to assist
people 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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
55
Service
Description
Coverage/
Limitations
Prior
Authorization
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.
No
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
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
56
Service
Description
Coverage/
Limitations
Prior
Authorization
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 six
months.
- Up to 210 minutes
of therapy
treatments per
week (maximum of
60 minutes per
day).
No
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.
We cover:
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
Specialized
Therapeutic
Services
Services provided
to children ages 0-
20 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
57
Service
Description
Coverage/
Limitations
Prior
Authorization
Speech-
Language
Pathology
Services
Services that
include tests and
treatments to help
you talk or swallow
better.
We cover the following
services for children
ages 0-20:
- 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 five
calendar 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 children
ages 0-20.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
58
Service
Description
Coverage/
Limitations
Prior
Authorization
Substance Abuse
Short-term
Residential
Treatment
Services/
Residential
Outpatient
Services
Short-term
substance abuse
treatment in a
residential
program for
pregnant adults.
Pregnant women ages
21 and over with a
substance use
disorder.
Up to 60 days per
calendar year.
Yes
Therapeutic
Behavioral
On-Site Services
Therapeutic
services provided
in the home or
community to
prevent children
ages 0-20 with
mental illnesses
from being placed
in a hospital or
other facility.
Up to nine hours per
month.
Yes
Transplant
Services
Services that
include all surgery
and pre- and post-
surgical care.
Covered as medically
necessary.
Yes
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.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
59
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
Acupuncture
Insertion of thin
needles through
skin to treat pain,
stress and other
conditions.
Members 21 years and
older.
Up to 40 units per
calendar year (1 unit =
15 minutes).
Yes
Cellular phone
service
Additional minutes
for Safelink phone
or Connections Plus
plan.
Members 18 years and
older.
No
Chiropractic
Services provided
by chiropractors.
Members 21 years and
older.
Up to 12 additional
visits per calendar year
(total of 36 visits).
No
Contact lenses
Contact lens types:
spherical, PMMA,
toric or prism
ballast, gas
permeable,
extended wear,
hydrophilic,
spherical, toric or
prism ballast; and
hydrophilic
extended wear,
other types.
Members ages 21 and
older.
Six-month supply.
No
CVS discount
program
20 percent discount
on certain over-the-
counter items.
No age limit.
No
Doula services
Pregnancy,
postpartum and
newborn care and
assessment
provided in your
home by a Doula.
Ages 13 and older.
No limits.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
60
Service
Description
Coverage/
Limitations
Prior
Authorization
Durable medical
equipment and
supplies
Breast pump
Additional coverage
for items not
covered for
members age 21
and older, such as
wound supplies,
hospital bed and
mattresses, insulin
pump and infusion
pump.
• Breast pump,
hospital grade
rental
• Breast pump
rental
Ages 21 and older.
One per calendar year;
ages 10 to 59.
One every 2 calendar
years; ages 10 to 59.
Yes, for some
equipment and
supplies.
Yes
Yes
Eye exam
Routine eye exam.
Ages 21 and older.
One per year based on
date of service.
No
Eye glasses
Prescription
eyeglasses.
Ages 21 and older.
One per year based on
date of service.
No
Hearing services
Hearing services
include:
assessment,
hearing evaluation,
hearing aid fitting,
hearing aid
monaural in ear,
behind ear hearing
aid, hearing aid
dispensing fee, in
ear binaural hearing
aid, behind ear
binaural hearing
aid, behind ear cors
hearing aid and
behind ear bicros
hearing aid.
Ages 21 and older.
All services limited to
one every two calendar
years, except for
hearing aid monaural
in ear, which is one per
calendar year.
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
61
Service
Description
Coverage/
Limitations
Prior
Authorization
Home delivered
meals post
inpatient
discharge
Meals delivered to
your home after a
hospitalization.
No age limit.
Up to 10 meals for
members in case
management.
Yes
Home visit by a
social worker
Home visit by a
clinical social
worker to assess
your needs and
provide available
options and
education to
address those
needs.
Ages 21 and older.
48 visits per calendar
year.
Yes
Massage
therapy
Massage of soft
body tissues to help
injuries and reduce
pain.
Ages 21 and older.
Up to 40 units per
calendar year (1
unit=15 minutes).
Yes
Meals – non-
emergency
transportation
day trips
Meals during non-
emergency
transportation
services.
No age limit.
$200 per day up to
$1,000 per calendar
year for trips over 100
miles.
Yes
Newborn
circumcision
Can be provided in
a hospital, office or
outpatient setting.
Birth to 28 days old.
One per lifetime if
medically necessary.
No
Nutritional
counseling
Outpatient visits
with a dietician for
members.
Ages 21 and older.
Unlimited.
Yes
Occupational
therapy
Treatments that
help you do things
in your daily life,
like writing, feeding
yourself and using
items around the
house.
Ages 21 and older.
One evaluation per
calendar year.
One re-evaluation per
calendar year.
Up to seven therapy
visits per week.
Yes, except
initial evaluation.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
62
Service
Description
Coverage/
Limitations
Prior
Authorization
Outpatient
hospital service
Service provided in
a hospital setting on
an outpatient basis.
Ages 21 and older.
Unlimited.
Yes, for some
services.
Over-the-counter
benefit
Coverage 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.
All ages.
Up to $25 per
household, per month.
No
Physical therapy
Physical therapy in
an office setting.
Ages 21 and older.
One evaluation per
calendar year.
One re-evaluation per
calendar year.
Up to seven treatment
units per week.
Yes, except
initial evaluation.
Prenatal/
perinatal visits
Prenatal/perinatal
office visits.
Ages 10 to 59.
14 visits for low-risk
pregnancy.
18 visits for high-risk
pregnancy.
No
Primary care
visits
Visits to primary
care provider.
Ages 21 and older.
Unlimited.
No
Postpartum visits
Doctor visits after
delivery of your
baby.
Ages 10-59.
Three visits within 90
days of delivery.
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
63
Service
Description
Coverage/
Limitations
Prior
Authorization
Respiratory
therapy
Respiratory therapy
in an office setting.
One initial evaluation
or re-evaluation per
calendar year.
One visit per calendar
year in office.
No
Speech
language
therapy
Speech and
language therapy
services in the
office setting.
Ages 21 and older.
One evaluation/re-
evaluation per
calendar year.
One AAC re-evaluation
per calendar year.
One evaluation of oral
pharyngeal swallowing
per calendar year.
Up to seven therapy
treatment units per
week.
AAC fitting, adjustment
and training; up to four
30-minute sessions per
calendar year.
Yes, except
initial evaluation.
Vaccines:
TDaP
Influenza
Shingles
Pneumonia
Vaccines to prevent
disease.
Ages 21 and older.
One per pregnancy.
One per calendar year.
As medically needed.
As medically needed.
No
No
Yes, for ages
21-65.
Yes, for ages
21-65.
Waived
copayments
All services,
including behavioral
health.
Ages 21 and older.
No
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
64
Service
Description
Coverage/
Limitations
Prior
Authorization
Assessment
services –
limited functional
mental health
assessment
Standard
assessment of
mental health
needs and
progress.
Ages 21 and older.
Two additional
assessments per
calendar year for a
total of three.
Yes
Intensive
outpatient
treatment
Intensive outpatient
treatment for
alcohol or drug
services and
behavioral health
treatment or
services.
Ages 21 and older.
Unlimited.
Yes
Therapy – Art
Art therapy
delivered in an
outpatient setting.
Must be delivered
by a behavioral
health clinician with
art therapy
certification.
Ages 21 and older.
Unlimited.
Yes
Therapy
(individual or
family)
One-on-one
individual mental
health therapy.
Ages 21 and older.
56 additional units for a
total of 160 units per
calendar year (one unit
= 15 minutes).
Yes
Therapy (group)
Mental health
therapy in a group
setting.
Ages 21 and older.
60 additional units for a
total of 216 units per
calendar year (one unit
= 1 minute).
Yes
Targeted case
management for
members with a
substance use
disorder
A service to help
those with
substance use
disorders get
needed care and
coordinate other
needed services.
Ages 21 and older.
Must have a substance
use disorder.
80 hours per calendar
year (this is in addition
to the 344 units
available for adult
mental health targeted
case management).
Yes
Your Plan Benefits: Behavioral Health Enhanced Benefits
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
65
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 you are in the LTC program. If you are not in the LTC
program, skip to Section 15)
Starting Services
It is important that we learn about you so we can make sure you get the care that you
need. Your 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 health, how you take care of
yourself, how you spend your time, who helps takes care of you and other things.
These questions make up your initial assessment. The initial assessment helps us
learn about what you need to live safely in your home. It also helps us decide what
services will help you the most.
Developing a Plan of Care
Before you can begin to get services under the LTC program, you have to have a
person-centered plan of care (plan of care). Your case manager makes your plan
of care. Your plan of care is the document that tells you all about the services you get
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
66
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 you. Your
plan of care will tell you:
• What services you are getting
• Who is providing your service (your service providers)
• How often you get a service
• When a service starts and when it ends (if it has an end date)
• What your services are trying to help you do. For example, if you need help
doing small chores around your house, your plan of care will tell you that
an adult companion care provider comes two days a week to help with your
chores.
• How your LTC services work with other services you get from outside our
Plan, such as from Medicare, your church or other federal programs
• Your personal goals
We don’t just want to make sure that you are living safely. We also want to make
sure that you are happy and feel connected to your community and other people.
When your case manager is making your plan of care, they will ask you about any
personal goals you might have. These can be anything, really, but we want to make
sure that your LTC services help you accomplish your goals. Some examples of
personal goals include:
• Walking for 10 minutes every day
• Calling a loved one once a week
• Going to the senior center 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
with us about your care) must sign your 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 plan of care. They will also
share it with your other health care providers.
Updating your Plan of Care
Every month your case manager will call you to see how your services are going and
how you are doing. If any changes are made, she or he will update your plan of care
and get you a new copy.
Your case manager will come to see you in person to review your plan of care every
90 days (or about three months). This is a good time to talk with them about your
services, what is working and isn’t working for you, and how your goals are going.
They will update your plan of care with any changes. Every time your plan of care
changes, you or your authorized representative must sign it.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
67
Remember, you can call your case manager any time to talk about problems you
have, changes in your 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 you a bath.
Remember, if you have any problems getting your services, call your case manager.
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
7
.
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 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
individual needs.
Service
Description
Coverage/
Limitations
Prior
Authorization
Adult Day
Health 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
7
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 1-866-796-0530 or TTY at 1-800-955-8770
68
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 1-866-796-0530 or TTY at 1-800-955-8770
69
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.
No
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 1-866-796-0530 or TTY at 1-800-955-8770
70
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 necessary.
No
Intermittent and
Skilled Nursing
Extra nursing help if
you do not need
nursing supervision all
the time o
r need it at a
regular time.
Per assessed need.
Yes
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
71
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 1-866-796-0530 or TTY at 1-800-955-8770
72
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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
73
Service
Description
Coverage/
Limitations
Prior
Authorization
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
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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
74
• Personal care services
• Adult companion care services
• Intermittent and skilled nursing care services
PDO lets you self-direct your services. This means you get to choose your service
provider and how and when you get your service. You have to hire, train and
supervise the people who work for you (your direct service workers).
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 facility for a
minimum of 30 days
between episodes.
No
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.
No
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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
75
Section 15: Member Satisfaction
Complaints, Grievances and Plan Appeals
We want you to be happy with us and the care you receive 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.
1-866-796-0530
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. 1-866-796-0530
(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.
You can contact us at:
Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL
33345-9087
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 1-866-796-0530 or TTY at 1-800-955-8770
76
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. 1-866-796-
0530 (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.
You can contact us at:
Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL
33345-9087
1-866-796-0530
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.
You can contact us at:
Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL
33345-9087
1-866-796-0530
• 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 1-866-796-0530 or TTY at 1-800-955-8770
77
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
Ft. 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 name
• Your member number
• Your 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 1-866-796-0530 or TTY at 1-800-955-8770
78
You may ask for a review by the State by calling or writing to:
Agency for Health Care Administration
P.O. Box 60127
Ft. 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 you are 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 services are continued,
there will be no change in your services until a final decision is made.
If your 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 Medicaid benefits.
We cannot ask your family or legal representative to pay for the services.
To have your 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 services will be reduced, suspended or
terminated
Section 16: Your Member Rights
As a recipient of Medicaid and a member in a Plan, you also have certain rights. You
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
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
• Be given easy to follow information about your diagnosis, the treatment you
need, choices of treatments and alternatives, risks and how these
treatments will help you
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
79
• Make choices about your health care and say no any treatment, except as
otherwise provided by law
• Be given full information about other ways to help pay for your 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, or source of payment
• Receive treatment for any health emergency that will get worse if you do
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 doctor (second
medical opinion)
• Get a copy of your medical record and ask to have information added or
corrected in your record, if needed
• Have your medical records kept private and shared only when required by
law or with your approval
• Decide how you want medical decisions made if you can’t make them
yourself (advanced directive)
• To file a grievance about any matter other than a Plan’s decision about
your services
• To appeal a Plan’s decision about your services
• Receive services from a provider that is not part of our Plan (out-of-
network) if we cannot find a provider for you 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 of where you live
• Receive information about being involved in your community, setting
personal goals and how you can participate in that process
• Be told where, when and how to get the services you need
• To be able to take part in decisions about your health care
• To talk openly about the treatment options for your conditions, regardless
of cost or benefit
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
80
• To choose the programs you participate in and the providers that give you
care
Section 17: Your Member Responsibilities
As a recipient of Medicaid and a member in a Plan, you also have certain
responsibilities. You have the responsibility to:
• Give accurate information about your health to your Plan and providers
• Tell your provider about unexpected changes in your health condition
• Talk to your provider to make sure you understand a course of action and
what is expected of you
• Listen to your 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 you have a change in information (address,
phone number, etc.)
• Have a plan for emergencies and access this plan if necessary for your
safety
• Report fraud, abuse and overpayment
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
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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
81
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:
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 1-866-796-0530. You may also send an email to
Compliancefl@centene.com
Abuse/Neglect/Exploitation of People
You should never be treated badly. It is never okay for someone to hit you or make
you feel afraid. You can talk to your PCP or case manager about your feelings.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
82
If you feel that you are 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 you are hurt, call your PCP
• If you need 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 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 advanced directive form from this website:
http://www.floridahealthfinder.gov/reports-guides/advance-directives.aspx.
Make sure that someone, like your PCP, lawyer, family member, or case manager
knows that you have an advance directive and where it is located.
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 1-866-796-0530 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
83
To take a look at Sunshine Health’s HEDIS results, please visit
https://www.sunshinehealth.com/members/medicaid/resources/quality-
improvement.html
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/FLKid
Care/MediKids.shtml
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
84
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
(ADRC).
Independent Consumer Support Program
The Florida Department of Elder Affairs also offers an Independent Consumer
Support Program (ICSP). The ISCP 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 ____________________________________ to act on my behalf in determining
Name of Representative
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
85
Mail to: Sunshine Health Attn: Privacy Officer,
P.O. Box 459089 Fort Lauderdale, FL 33345-9089
Phone: 1(866) 796‐0530 or TTY 1‐800‐955‐8770
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.
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: _________________________________________
_______________________________________________________________________________
86
Mail to: Sunshine Health Attn: Privacy Officer,
P.O. Box 459089 Fort Lauderdale, FL 33345-9089
Phone: 1(866) 796-0530 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;
OR
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: __________________________
87
Mail to: Sunshine Health Attn: Privacy Officer,
P.O. Box 459089 Fort Lauderdale, FL 33345-9089
Phone: 1(866) 796-0530 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: (____) _____ - ________
88
Mail to: Sunshine Health Attn: Privacy Officer,
P.O. Box 459089 Fort Lauderdale, FL 33345-9089
Phone: 1(866) 796-0530 or TTY 1-800-955-8770
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: ________________________________________ Date: ____/_____/_____
(Member or Legal Representative Sign Here)
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.
89
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
90
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
91
This
form is confidential. If you have any problems or questions, please call Sunshine Health at
1-866-796-0530 (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?
© 2011 Start Smart for Your Baby. All rights reserved.
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
92
Do you have enough food? Yes No Are you enrolled in WIC? Yes
No
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
No
List:Current STD? Yes No
Amount:Current tobacco use? Yes
No
If yes, are you interested in quitting?
Yes
No
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
FL-MNOP-2008-2© 2011 Start Smart for Your Baby. All rights reserved.
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
93
1-866-796-0530
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
1.
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:
2.
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):
94
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
95
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 Child Welfare,
please call Member Services for help at 1-866-
796-0530 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
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
96
Si necesita este cuadernillo en formatos
alternativos, por favor, llame a Servicios para
Miembros para pedir ayuda al 1-866-796-0530
o TTY 1-800-955-8770.
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 1-866-796-0530 ou TTY 1-800-
955-8770.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
97
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 1-866-796-
0530 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 numero 1-866-796-0530 o TTY al
1-800-955-8770.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
98
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 1-866-
796-0530 или TTY 1-800-955-8770.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
99
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 1-866-796-0530 or 1-
855-955-8770 (Relay FL 1-800-
955-8770).
If you believe that Sunshine Health has failed to provide these services or
discriminated in
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, 1-866-
796-0530 (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 of
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 1-866-796-0530 or TTY at 1-800-955-8770
100
This information is available for free in other
languages. Please contact our customer service
number at 1-866-796-0530, 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 1-866-796-0530,
TTY 1-800-955-8770 de lunes a viernes, de 8 a.m.
a 8 p.m.
Questions? Call Member Services at 1-866-796-0530 or TTY at 1-800-955-8770
101
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MMA LTC Member Handbook (Sunshine Health)

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Completed 31 January 2021

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