Benefits Overview

Your Sunshine Health Pathway to Shine Specialty Plan Benefits

This table lists the medical services covered by Sunshine Health. Remember, your child may need a referral from your child’s primary care provider (PCP) or approval from us before you go to an appointment or use a service. Services must be medically necessary (PDF) for us to pay for them.

There may be some services that we do not cover, but might still be covered by Medicaid. To find out about these benefits, call the Agency Medicaid Help Line at 1-877-254-1055. If you need a ride to any of these services, we can help you. See Transportation Services.

If there are changes in covered services or other changes that 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 at 1-855-463-4100.

Except for emergency care, Sunshine Health must prior authorize any services to out-of-network providers and any elective inpatient admissions.

*Denotes services that are behavioral health in lieu of services. This means they are optional services you can choose over more traditional services based on your needs.

Your Sunshine Health Pathway to Shine Specialty Plan Expanded Benefits
Service	Description	Coverage/Limitations	Prior Authorization
Addictions Receiving Facility Services*	Services used to help people who are struggling with drug or alcohol addiction	As medically necessary and recommended by us	No prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.
Allergy Services	Services to treat conditions such as sneezing or rashes that are not caused by an illness	We cover medically necessary blood or skin allergy testing and up to 156 doses per 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*	Services provided to people who are withdrawing from drugs or alcohol	As medically necessary and recommended by us	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
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 years and older) help with activities of daily living and taking medication	We cover 365/366 days of services per year, as medically necessary.	Yes
Behavior Analysis (BA)	Structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors.	We cover recipients under the age of 21 years requiring medically necessary services.	No
Behavioral Health Assessment Services	Services used to detect or diagnose mental illnesses and behavioral health disorders	We cover, as medically necessary: One initial assessment per year One reassessment per year Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)	No
Behavioral Health Overlay Services	Behavioral health services provided to children (ages 0-18 years) enrolled in a DCF program	We cover 365/366 days of medically necessary services per year, including therapy, support services and aftercare planning	Yes
Behavioral Health Services – Child Welfare*	A special mental health program for children enrolled in a DCF program	As medically necessary and recommended by us	No
Cardiovascular Services	Services that treat the heart and circulatory (blood vessels) system	We cover the following as prescribed by your doctor, when medically necessary: Cardiac testing Cardiac surgical procedures Cardiac devices	Yes, for some services
Child Health Services Targeted Case Management	Services provided to children (ages 0-3 years) to help them get healthcare and other services OR Services provided to children (ages 0-20 years) who use medical foster care services	Your child must be enrolled in the DOH Early Steps program OR Your child must be receiving medical foster care services	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, as medically necessary: 24 patient visits per year, per member X-rays	No
Clinic Services	Healthcare services provided in a county health department, federally qualified health center, or a rural health clinic	Covered as medically necessary	No
Community-Based Wrap-Around Services*	Services provided by a mental health team to children who are at risk of going into a mental health treatment facility	As medically necessary and recommended by us	Yes
Crisis Stabilization Unit Services*	Emergency mental health services that are performed in a facility that is not a regular hospital	As medically necessary and recommended by us	No
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, when medically necessary: Hemodialysis treatments Peritoneal dialysis treatments	No
Drop-In Center Services*	Services provided in a center that helps homeless people get treatment or housing	As medically necessary and recommended by us	No
Durable Medical Equipment and Medical Supplies Services	Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is reused, and includes things like wheelchairs, braces, crutches, and other items. Medical supplies are items meant for one-time use and then thrown away	As medically necessary, some service and age limits apply. Call Member Services for more information.	Prior authorization may be required for some equipment or services.
Early Intervention Services	Services to children ages 0-3 years who have developmental delays and other conditions	We cover medically necessary: One initial evaluation per lifetime, completed by a team Up to 3 screenings per year Up to 3 follow-up evaluations per year Up to 2 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
Evaluation and Management Services	Services for doctor’s visits to stay healthy and prevent or treat illness	We cover medically necessary: One adult health screening (check-up) per 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 medically necessary: Up to 26 hours per year	No
Family Training and Counseling for Child Development*	Services to support a family during their child’s mental health treatment	As medically necessary and recommended by us	No
Gastrointestinal Services	Services to treat conditions, illnesses, or diseases of the stomach or digestion system	Covered as medically necessary	Yes, for some services
Genitourinary Services	Services to treat conditions, illnesses, or diseases of the genitals or urinary system	Covered as medically necessary	Yes, for some services
Group Therapy Services	Services for a group of people to have therapy sessions with a mental health professional	We cover medically necessary: Up to 39 hours per year.	No
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, when medically necessary: Cochlear implants One new hearing aid per ear, once every 3 years Repairs	Yes, for some services
Home Health Services	Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury	We cover, when medically necessary: Up to 4 visits per day for pregnant recipients and recipients ages 0-20 years Up to 3 visits per day for all other recipients	Yes
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-to-one therapy sessions with a mental health professional	We cover medically necessary: Up to 26 hours per year.	No
Infant Mental Health Pre and Post Testing Services*	Testing services by a mental health professional with special training in infants and young children	As medically necessary and recommended by us	No
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, when medically necessary: Up to 365/366 days for recipients ages 0-20 years Up to 45 days for all other recipients (extra days are covered for emergencies)	Yes
Integumentary Services	Services to diagnose or treat skin conditions, illnesses or diseases	Covered as medically necessary	Yes, for some services
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 Partial Hospitalization Program Services*	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from mental illness	As medically necessary and recommended by us	Yes
Mental Health Targeted Case Management	Services to help get medical and behavioral healthcare for people with mental illnesses	Covered as medically necessary	No
Mobile Crisis Assessment and Intervention Services*	A team of health care professionals who provide emergency mental health services, usually in people’s homes	As medically necessary and recommended by us	No
Multisystemic Therapy Services*	An intensive service focused on the family for children at risk of residential mental health treatment	As medically necessary and recommended by us	No
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 disabled people, a taxi, or other kinds of vehicles	We cover the following services for recipients 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	Yes
Occupational Therapy Services	Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house	We cover for children ages 0-20 years and for adults under the $1,500 outpatient services cap, as medically necessary: 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, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later.	Yes, for some services
Oral Surgery Services	Services that provide teeth removals and to treat other conditions, illnesses or diseases of the mouth and oral cavity	Covered as medically necessary	Yes, for some services
Orthopedic Services	Services to diagnose or treat conditions, illnesses or diseases of the bones or joints	Covered as medically necessary	Yes, for some services
Outpatient Hospital Services	Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.	Emergency services are covered as medically necessary. Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 years 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*	Services for people leaving a hospital for mental health treatment	As medically necessary and recommended by us	Yes
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 years and for adults under the $1,500 outpatient services cap, as medically necessary: 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, as medically necessary: 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, as medically necessary: Up to 24 office visits per 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 healthcare provider	We cover, as medically necessary: Up to a 34-day supply of drugs, per prescription Refills, as prescribed	Yes, for some services
Private Duty Nursing Services	Nursing services provided in the home to people ages 0-20 years who need constant care	We cover, as medically necessary: Up to 24 hours per day.	Yes
Psychiatric Specialty Hospital Services*	Emergency mental health services that are performed in a facility that is not a regular hospital	As medically necessary and recommended by us	No
Psychological Testing Services	Tests used to detect or diagnose problems with memory, IQ or other areas	We cover, as medically necessary: 10 hours of psychological testing per year.	No
Psychosocial Rehabilitation Services	Services to assist people reenter everyday life. They include help with basic things such as cooking, managing money and performing household chores.	We cover, as medically necessary: Up to 480 hours per year.	No
Radiology and Nuclear Medicine Services	Services that include imaging such as X-rays, MRIs or CAT scans. They also include portable X-rays	Covered as medically necessary	Yes, for some services
Regional Perinatal Intensive Care Center Services	Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions	Covered as medically necessary	Yes, for some services
Reproductive Services	Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family	We cover medically necessary 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
Respiratory Services	Services that treat conditions, illnesses or diseases of the lungs or respiratory system	We cover medically necessary: Respiratory testing Respiratory surgical procedures Respiratory device management	Yes, for some services
Respiratory Therapy Services	Services for recipients ages 0-20 years to help you breathe better while being treated for a respiratory condition, illness or disease	We cover medically necessary: One initial evaluation per year One therapy re-evaluation per 6 months Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)	No
Self-Help/Peer Services*	Services to help people who are in recovery from an addiction or mental illness	As medically necessary and recommended by us	No
Specialized Therapeutic Services	Services provided to children ages 0-20 years with mental illnesses or substance use disorders	We cover the following medically necessary: Assessments Foster care services Group home services	Yes
Speech-Language Pathology Services	Services that include tests and treatments help you talk or swallow better	We cover the following medically necessary services for children ages 0-20 years: Communication devices and services Up to 210 minutes of treatment per week One initial evaluation per year We cover the following medically necessary services for adults: One communication evaluation per 5 years.	Yes
Statewide Inpatient Psychiatric Program Services	Services for children with severe mental illnesses that need treatment in the hospital	Covered as medically necessary for children ages 0-20 years	Yes
Substance Abuse Intensive Outpatient Program Services*	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders	As medically necessary and recommended by us	Yes
Substance Abuse Short-term Residential Treatment Services*	Treatment for people who are recovering from substance use disorders	As medically necessary and recommended by us	Yes
Therapeutic Behavioral On-Site Services	Services provided by a team to prevent children ages 0-20 years with mental illnesses or behavioral health issues from being placed in a hospital or other facility	We cover medically necessary services: Up to 9 hours per month.	No
Transplant Services	Services that include all surgery and pre and post-surgical care	Covered as medically necessary	Yes
Visual Aid Services	Visual Aids such as glasses, contact lenses and prosthetic (fake) eyes	We cover the following medically necessary services when prescribed by your doctor: Two pairs of eyeglasses for children ages 0-20 years One frame every two years and two lenses every 365 days for adults ages 21 years and older 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

Expanded benefits are extra goods or services we provide to you, free of charge. Call Member Services to ask about getting expanded benefits.

Your Sunshine Health Pathway to Shine Specialty Plan Expanded Benefits
Service	Description	Coverage/Limitations	Prior Authorization
Behavioral Health Integration/ Collaborative Care	Unlimited visits for members with providers who manage both physical and mental health needs.	None	No
Biometric Equipment	Digital blood pressure cuff and weight scale	Ages 13 years and older. One (1) digital blood pressure cuff every three (3) years; One (1) weight scale every three (3) years	No
Camp Scholarship	$150 voucher to attend children’s camp. Must be enrolled in Care Management and have completed annual wellness exam.	Ages 4-18 years	Contact your care manager to determine eligibility.
Care Grant	Up to $150 per year for tutoring, gym memberships, swimming lessons, sports equipment/supplies, or art supplies/workbooks	Ages up to 18 years	Contact your care manager to determine eligibility.
Caregiver Swimming Lessons	One group session, up to 8 lessons from local YMCA. In areas where a YMCA does not exist, members may use a local swim vendor.	Ages 18 years and older. In areas where YMCA doesn’t exist, members may use a local swim vendor.	No
Cellular Services	Members can receive a free smartphone. The phone includes minutes, data and texts.	Ages 16 years and older	No
Childcare	Voucher for childcare to help parents identified with childcare needs on Pathways to Prosperity screening	$150 limit. Must be age 16 years and older	Contact your care manager to determine eligibility.
Circumcision (newborns only)	Male circumcision is a common procedure typically performed in the first month after birth. Can be provided in a hospital, office or outpatient setting.	Birth to 28 days old. One per lifetime if medically necessary	No
Dental Kit	One dental hygiene kit per year for pregnant members who attend a Sunshine Health-sponsored event	Ages 13 years and older	No
Doula Services	Pregnancy, postpartum and newborn care and assessment provided in your home by a doula. Using a doula during pregnancy, birth, and postpartum has been shown to be an effective best practice that can enhance the birthing experience, reduce complications, and improve outcomes for women and infants.	Ages 13 years and older. No limits	No
Durable Medical Equipment/ Asthma Supplies	Unlimited hypoallergenic bedding and one (1) high-efficiency particulate air (HEPA) filter vacuum cleaner for members diagnosed with asthma.	Must have asthma or COPD diagnosis	Contact your care manager to determine eligibility.
Educational Vouchers	$150 voucher after completion of Sunshine Health Works Launchpad Educational Modules	Ages 16 years and older	No
Expanded Prenatal Services	14 visits for low-risk pregnancy 18 visits for high-risk pregnancy Breast pump, hospital grade rental Breast pump	Ages 13 years and up One per calendar year; Ages 13 years and up One every 2 calendar years; ages 13 years and up	No No Yes No
Flu Prevention Kit	1 Flu Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer	Ages 18 years and older. For the first 1,000 members who get their flu vaccine.	No
Foster Care Comfort Kits	A sturdy backpack or duffle bag filled with items to make entering a foster home easier, such as a blanket, journal and pen, hygiene supplies, educational books and games, soft bear, stress ball, fidget spinner, and/or earbuds.	Must be enrolled in Sunshine Health Pathway to Shine Specialty Plan. Up to 18 years old	No
Grocery Benefit	$50 food gift card per household per year for enrollees who identify as food insecure on Pathways to Prosperity screening	Ages 16 years and older	Contact your care manager to determine eligibility.
Housing Assistance	A maximum of $250 per community-based enrollee per year to assist with housing related expenses (rent, utilities, etc.)	Must be 16 years or older. Funds are paid directly to the utility company or place where assistance is needed.	Contact your care manager to determine eligibility.
Home Delivered Meals - General & Disaster Preparedness	Access to healthy food during an emergency, such as a natural disaster, can be difficult.	1 emergency meal kit annually	Yes
Home Delivered Meals - Post Transition Meals	Meals delivered to your home after discharge from hospital or nursing facility.	No age limit. Unlimited as deemed medically necessary	Yes
Home Delivered Meals for Enrollees who are Pregnant	266 meals to enrollees who are at least 20 weeks pregnant and have a qualifying medical condition	Up to four months postpartum	Contact your care manager to determine eligibility.
Homemaker Services (e.g. hypoallergenic carpet cleanings)	Preventing allergen build up in home carpets is a vital measure to help alleviate symptoms.	Up to two cleanings per year. Must be diagnosed with asthma to qualify.	Contact your care manager to determine eligibility.
Joy for All Battery Operated Plus Companion Pet	Designed to bring comfort, companionship, and fun to individuals experiencing social isolation, loneliness, or any type of cognitive decline.	One pet per member.	Contact your care manager to determine eligibility.
Legal Guardianship	Legal guardianship can help protect an individual who is no longer able to make decisions for themselves that are in the best interest of their health and well-being. Maximum of five hundred dollars ($500) per eligible enrollee per lifetime	This is available to members who are in a SNF or PDN setting and parent is obtaining guardianship to protect those who are unable to care for their own well-being. Available for members aged 17 through 21 years.	Contact your care manager to determine eligibility.
Meal Stipend (available for long distance medical appointment day trips)	To support enrollees of all ages who need to travel long distance for medical appointments, available for long distance medical appointment day trips.	Up to twenty dollars ($20) per meal up to 3 meals per day; up to two hundred dollars ($200) per day; up to one thousand dollars ($1,000) per year for trips greater than one hundred (100) miles	Yes
Nursing Facility Transition Assistance	To help families of children living in a nursing facility to bring their child home. The benefit will provide assistance to the children and their families to help overcome barriers preventing the child from living at home with their family.	For individuals currently residing in a nursing facility and are either under 21 years old or under 30 years of age and have been living in a nursing facility before turning 21 years old. Lifetime limit: $65,000	Yes
Over-the-Counter Benefit	Coverage for cold, cough, allergy, vitamins, supplements, ophthalmic/otic preparations, pain relievers, gastrointestinal products, first aid care, hygiene products, insect repellent, oral hygiene products and skin care	All ages. Up to $50 per household, per month	No
Palliative Care	Up to 20 days per year of palliative care for enrollees living with chronic illness. Includes personal care assistance.	Ages 5-75 years	Yes
Peer Support Certification	Up to $600 voucher to become a Peer Support Specialist for members who identify as needing job support on a Pathways to Prosperity screening	Ages 16 years and older	Contact your care manager to determine eligibility.
Respite Care	Provides caregivers a temporary rest from caregiving of members with special healthcare needs	Up to 200 hours in-home and up to 10 days out-of-home per year. Must have exhausted all covered and community-based respite benefits	Yes
Sensory Kit	Sensory support kit tailored to the developmental and diagnosis needs of enrollees.	Ages 3 years and older	Contact your Care Manager to determine eligibility.
Swimming Lessons (children only)	Children under age 21 can receive group swim sessions which include up to 8 lessons from a local YMCA.	One group session, up to 8 lessons from local YMCA. In areas where a YMCA does not exist, members may use a local swim vendor.	No
Tattoo Removal	Voucher for members who have completed Sunshine Health Works Launchpad Educational modules who provide proof of workforce need.	One per lifetime; $500 limit, Ages 18-26 years	Contact your Care Manager to determine eligibility.
Tutoring	Voucher to aid in removing educational barriers	Twelve (12) annual tutoring sessions up to 2 hours of tutoring time per session. Ages 16 years and up	Contact your Care Manager to determine eligibility.
Transportation Services to Non-Medical Appointments/Activities	Up to three trips a month for non-medical purposes such as shopping or social events.	Ages 0 to 21 years old. Must not have another means of transportation to qualify	No
Vital Records Support	$50 reimbursement for copies of personal documentation, such as driver’s license or birth certificate	Ages 16 years and older	No
Welcome Baby! Bundle	One gift package for pregnant members. Choose one option per pregnancy: 1) Safe Sleep Survival Kit with Cribette, 2) Car Seat with safe sleep educational materials, 3) Highchair with safe sleep educational materials, 4) Baby Shower in a Box, or 5) Stroller with safe sleep educational materials.	Must complete three prenatal visits and attend a Sunshine Health-sponsored event	No
YMCA Membership	For individuals or family of four. Includes access to free standing YMCA facilities and Y360 virtual platform	Ages 18 years and older. Caregiver, parent or guardian must be present for ages 17 years and under.	No

Benefits Overview

Your Sunshine Health Pathway to Shine Specialty Plan Benefits

Your Sunshine Health Pathway to Shine Specialty Plan Benefits

Your Sunshine Health Pathway to Shine Specialty Plan Expanded Benefits