Enrollee Benefits

Services Covered by Sunshine Health Long Term Care

In order for services to be covered Sunshine Health Long Term Care must approve them.  Services by out of network providers may not be paid. Talk to your Case Manager about out of network providers. You will always have the freedom to choose.  You may choose providers from our network of providers.  Sunshine Health Long Term Care will not restrict your right to services based on moral or religious grounds.

Member General Brochure [PDF]

BENEFITS COVERAGE EXCLUSIONS AND LIMITATIONS
Adult Companion Services Non-medical care, supervision and socialization. Based on care plan need.
Adult Day Health Center Social and health activities in an organized day program at a center. Meal included when enrollee is at the center during mealtime. Based on care plan need.
Assisted Living Services Services such as personal care, housekeeping, medication oversight and social programs to assist the enrollee in an assisted living facility. The enrollee is responsible for paying the assisted living facility room and board amount. The Florida Department of Children and Families (DCF) will evaluate the enrollee’s income to determine if additional money needs to be paid to the assisted living facility by the enrollee. If the enrollee resides in a room other than a standard semi-private room, the facility may possibly charge an additional amount. Family supplementation is allowed to pay the difference in cost between a shared and private room as long as the payment is made directly to the facility.
Assistive Care Services Integrated set of 24-hour services. Limited to enrollees who resided in adult family care homes.
Attendant Care Hands-on care, of both a supportive and health-related nature, specific to the needs of a medially stable, physically handicapped individual. Based on care plan need.
Behavioral Management Provides behavioral health care services to address mental health or substance abuse needs. Based on care plan need.
Care Management Help enrollee to obtain, coordinate and integrate services. Develop personal care plan. Visit enrollee to discuss needs. No limit
Caregiver Training Training and counseling services for the caregivers of the enrollee. Based on care plan need.
Chores Assistance with heavy household chores, such as washing floors and windows and moving heavy items of furniture to provide safe entry and exit. Based on care plan need.
Home Adaptation Services Adaptations to the enrollee’s home which are necessary to ensure health, welfare and safety, or which help the enrollee to function with greater independence in the home and without which the enrollee would require institutionalization. Excludes those adaptations or improvements to the home that are of general use and are not of direct medical or remedial benefit to the enrollee.
Homemaker General household activities, such as meal preparations and routine home chores. Based on care plan need.
Hospice Medical care and services designed to meet the physical, social, psychological and spiritual needs of the terminally ill and their families. Based on care plan need.
Intermittent and Skilled Nursing Skilled nursing services provided on an intermittent basis to enrollees who do not require continuous nursing supervision or whose need is predictable. Based on care plan need.
Meals Home delivered meals for enrollees who have difficulty preparing food without assistance. Nutritional supplements for enrollees who have a medical need. Based on care plan need.
Medical Equipment and Supplies Disposable diapers, gloves and other consumable medical supplies. Devices, controls or appliances that enable the enrollee to increase independence, control or communicate in their environment and items necessary for life support or to address physical conditions. Not included are personal toiletries, and household items such as detergent, bleach, and paper towels.
Medication Assistance Assistance with self-administration of medications, whether in the home or a facility Based on care plan need.
Medication Management Medication reviews by licensed nurses of all over-the-counter and prescription medications Based on care plan need.
Nursing Home Nursing home services are available for enrollees who require such services.  Skilled nursing home services are covered by Medicare The Florida Department of Children and Families will determine a patient’s financial responsibility.
Nutritional Assessment/Risk Reduction Assessment and guidance about nutrition. Based on care plan need.
Occupational Therapy Treatment to restore, improve or maintain impaired functions aimed at increasing or maintaining the enrollee’s ability to perform tasks required for independent functioning. Determined through muti-disciplinary assessment
Personal Care Assistance in the home with bathing, dressing, eating, personal hygiene and other activities. Based on care plan need.
Personal Emergency Response Electronic device that helps a enrollee at high risk to get help in an emergency. See extended benefits for information about wireless Personal Emergency Response. Limited to enrollees 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 enrollee.
Physical Therapy Treatment to restore, improve or maintain impaired functions by use of physical, chemical and other properties of heat, light, electricity or sound and by massage and active, resistive or passive exercise. Determined through muti-disciplinary assessment.
Respiratory Therapy Treatment of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system. Determined through muti-disciplinary assessment.
Respite Personal care or supervision provided to an enrollee on a short-term basis due to the absence or need for relief of the person normally providing the care. Based on care plan need.
Speech Therapy Identification and treatment of neurological deficiencies related to feeding problems, congenital or trauma-related maxillofacial anomalies, autism or neurological conditions that effect oral motor functions. Determined through muti-disciplinary assessment.
Sunshine Health Nurse Care Line A nurse is available 24 hours a day, 7 days a week to help answer medical questions you may have. The number for the 24 hour Sunshine Health NurseWise Line is 1-877-211-1999 option 7. No limit
Transportation Non-emergency transportation. See extended benefits for additional transportation services. Based on care plan need.