Benefits Overview
New Benefits
At Sunshine Health, your health is our top priority. Together, with the State of Florida, we are focused on making it easier for you to get the care, resources, and support you need. We are adding new benefits, programs and member rewards designed to directly help improve your health.
As part of the Agency for Health Care Administration's "From the Start" maternal health initiative, Sunshine Health will be offering the following new benefits.
Some of these benefits may have limits or require authorization.
Support during and after pregnancy
Benefit | Description | Prior Auth |
|---|---|---|
24/7 Lactation Support | Pregnant members get 24/7 telephonic lactation support by calling 1-866-796-0530 (TTY 1-800-955-8770) | No |
Baby Book | Pregnant members receive an educational guide on pregnancy and newborn care | No |
Camp Scholarship | Up to $300 to attend group youth enrichment camp. Ages 4-18. Must be enrolled in Care Management and have completed annual wellness exam. | Contact your care manager |
Fatherhood Engagement Referral Program | Referral program for new dads | No |
First Year of Life Safe Sleep | One crib for baby per delivery. Must be aged 13 or older. Mother must complete a postpartum visit within 7-84 days. Baby must be enrolled in First Year of Life program, and complete six pediatrician visits within six months. | Contact your care manager |
Fresh Funds | $50 per month, up to 6 months post delivery Members must complete postpartum visit within 7-84 days, be aged 13 or older and be enrolled in Care Management for high risk pregnancy | Contact your care manager |
Mom Care Bundle | One bundle per pregnancy to support postpartum self-care. Must be aged 13 or older, have completed postpartum visit between 7 and 84 days post-delivery, and be enrolled in Care Management for high-risk pregnancy. | Contact your care manager |
Ready for Baby Bundles | Two bundles per delivery, including diapers, wipes, pacifiers, and more.
| Contact your care manager |
Remote Patient Monitoring | Remote patient monitoring program to support a healthy pregnancy | Contact your care manager |
Care that fits your life
Benefit | Description | Prior Auth |
|---|---|---|
Digital Youth Engagement Tool | Digital telehealth behavioral health platform that connects teens/young adults with Certified Peer Specialist Mentors. | No |
Digital Care Support for Adults | Digital behavioral health platform that supports adults with anxiety, depression, substance use disorder or schizophrenia. | No |
Help with meals, nutrition, and daily living
Benefit | Description | Prior Auth |
|---|---|---|
Medically Tailored Meals Diabetes | Up to 84 meals for 6 weeks for members with Diabetes. Must be aged 13 or older and enrolled in Care Management. | Contact your care manager |
Medically Tailored Meals Congestive Heart Failure (CHF) | Up to 84 meals for 6 weeks for members with CHF. Must be aged 13 or older and enrolled in Care Management. | Contact your care manager |
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.
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 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 Setting Substance Use Treatment and 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 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 | Yes |
Behavioral Health Assessment Services | Services used to detect or diagnose mental illnesses and behavioral health disorders | We cover, as medically necessary:
| No |
Behavioral Health - Crisis Stabilization Unit (CSU)* | Emergency mental health services that are performed in a facility that is not a regular hospital | As medically necessary and recommended by us. Maximum of 15 days per month for adults 21-65.
| No |
Behavioral Health Overlay Services | Behavioral health services provided to children (ages 0 – 18) enrolled in a DCF program | We cover 365/366 days of medically necessary services per year, including therapy, support services and aftercare planning | Yes |
Cardiovascular Services | Services that treat the heart and circulatory (blood vessels) system | We cover the following as prescribed by your doctor, when medically necessary:
| 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 OR Services provided to children (ages 0 – 20) 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 | Yes |
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:
| No |
Clinic Services | Health care 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. Ages 0-21 years old with a Serious Emotional Disturbance (SED) diagnosis who could benefit from community based wraparound as a diversion to higher levels of residential care. | Yes |
Detox at Addictions Receiving Facility (ARF)* | Services used to help people who are struggling with substance or alcohol use disorder | As medically necessary and recommended by us. Maximum of 15 days per month for adults 21-65. | 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. |
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:
| No |
Drop-In Center* | Members with a behavioral health diagnosis who could benefit from social skills support | As medically necessary and recommended by us. Ages 18 and up. | 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 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 | As medically necessary, some service and age limits apply. Call 1-855-463-4100 (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 medically necessary:
| 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:
| 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. For ages 0-21 years old with a Serious Emotional Disturbance (SED) diagnosis whose caregivers could benefit from assistance. | No |
Free Standing Psychiatric Hospital* | Emergency mental health services that are performed in a facility that is not a regular hospital | As medically necessary and recommended by us. Maximum of 15 days per month. Ages 21-65. | Yes |
Functional Family Therapy* | An intensive, short- term therapeutic model that offers in- home family counseling designed specifically to address behaviors (i.e., curfew violations, running away, and truancy) | Ages 11-18 with a history of DJJ involvement. As medically necessary. | 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:
| 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:
| 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 |
Housing Assistance (Transitional Housing Services)* | Services for people with homelessness or at risk for homelessness and diagnosis of SMI and/or SUD | Covered as medically necessary. Ages 21 and older. Up to 90 days per calendar year. | Yes |
Housing Assistance (Tenancy Sustaining Services)* | Services for people with homelessness or at risk for homelessness and diagnosis of SMI and/or SUD | Covered as medically necessary. Ages 21 and older. Up to 90 days per calendar year. | 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. Ages 0-5 old experiencing developmental delays, or having difficulty bonding with caregivers, who may benefit from specialized programs. | 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:
| Yes |
Integumentary Services | Services to diagnose or treat skin conditions, illnesses or diseases | Covered as medically necessary
| Yes, for some services |
Intensive Outpatient Program (IOP) for Mental Health* | Treatment provided for more than 3 hours per day, several days per week, for people who have a mental health condition | Covered as medically necessary and recommended by us | Yes
|
Intensive Outpatient Program (IOP) for Substance Use* | Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders | Covered as medically necessary and recommended by us | Yes |
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* | A team of healthcare professionals who provide emergency mental health services, usually in people’s homes or the community | Covered as medically necessary and recommended by us | No |
Multisystemic Therapy Services* | An intensive service for families with youth who are experiencing mental health issues and are at risk for or actively engaging in delinquent activity or substance use and are at risk for or in out of home placement | Covered as medically necessary and recommended by us. Members ages 12-17. | 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:
| 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 and for adults under the $1,500 outpatient services cap, as medically necessary:
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 extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity | Covered as medically necessary | Yes, for some services |
Orthopedic Services | Services to diagnose or treat conditions, illnesses or diseases of the bones or joints | Covered as medically necessary | Yes, for some services |
Outpatient Hospital Services | Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you | Emergency services are covered as medically necessary. Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 and over. | Yes, for some services |
Pain Management Services | Treatments for long-lasting pain that does not get better after other services have been provided | Covered as medically necessary. Some service limits may apply | Yes |
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, as medically necessary:
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:
| 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, as medically necessary:
| Yes, for some services |
Private Duty Nursing Services | Nursing services provided in the home to people ages 0 to 20 who need constant care | We cover, as medically necessary up to 24 hours per day | Yes |
Psychiatric Partial Hospitalization (PHP) Mental Health* | 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. Up to ninety (90) days annually for adults ages twenty-one (21) and older; there is no annual limit for children under the age of twenty-one (21). No day limit per calendar year. | Yes |
Psychiatric Partial Hospitalization (PHP) Substance Abuse* | Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from Substance Use Disorder | As medically necessary and recommended by us. Up to ninety (90) days annually for adults ages twenty-one (21) and older; there is no annual limit for children under the age of twenty-one (21). No day limit per calendar year. | Yes |
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 | Yes, for some services |
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 | 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:
| Yes, for some services |
Respiratory Therapy Services | Services for recipients ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease | We cover medically necessary:
| No |
Self-Help/Peer Support Services* | Services to help people who are in recovery from substance use disorder or mental illness | As medically necessary and recommended by us | No |
Short Term Residential Care* | Treatment for members with substance use or mental health diagnosis | As medically necessary and recommended by us. Maximum of 15 days. Ages 21-65. | Yes |
Skilled Nursing Facility* | Members for whom a skilled nursing facility can shorten the length of stay in an inpatient facility, or eliminate the need for an inpatient stay. Member does not require long-term nursing facility care and meets the requirements of PASRR. | As medically necessary and recommended by us. Maximum of 60 days per calendar year. | Yes |
Specialized Therapeutic Services | Services provided to children ages 0-20 with mental illnesses or substance use disorders | We cover the following medically necessary:
| 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:
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 | Yes |
Structured Family Caregiving* | Members residing in nursing facilities who can be transitioned safely in a community setting and for whom more intensive in-home assistance/support is needed | As medically necessary and recommended by us. Ages 18 and up. | Yes |
Therapeutic Behavioral On-Site Services | Services provided by a team to prevent children ages 0-20 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 are items such as glasses, contact lenses and prosthetic (fake) eyes | We cover the following medically necessary services when prescribed by your doctor:
| 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.
Service | Description | Coverage/ | Prior Authorization
|
|---|---|---|---|
Acupuncture | Insertion of thin needles through skin to treat pain, stress and other physical and mental health conditions | Ages 21 years and older. Unlimited as deemed medically necessary. | Yes |
Art Therapy | Therapy for behavioral health treatments provided by a certified clinician | Ages 21 years and older. Unlimited as deemed medically necessary. | Yes |
Baby Book | Pregnant members receive an educational guide on pregnancy and newborn care | Fill out your Notice of Pregnancy and enroll in Start Smart for your Baby | No |
| Behavioral Health Integration/Collaborative Care | Unlimited visits with providers who manage both physical and mental health needs | Must have a behavioral health condition | 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 |
Breast Pump |
|
|
|
Camp Scholarship | $300 benefit to attend group youth enrichment camp | Ages 4-18. Must be enrolled in Care Management and have completed annual wellness exam. | Contact your care manager to determine eligibility |
Care Bundle | Pre-selected bundles tailored to specific needs and age groups, to include sports/gym, art supplies, school/education or social activity; or reimbursement for tutoring, gym memberships, swimming lessons. Value of up to $150 per year per child. | Ages up to 21. Must be enrolled in Care Management. | Contact your care manager to determine eligibility |
Caregiver Swimming Lessons | Caregivers 18 years and older of Sunshine Health members ages 0-21 can get group swim sessions at the YMCA. Show member's ID card at the YMCA front desk to sign up. | One group session (up to 8 lessons) per calendar year. In areas where a YMCA does not exist, caregivers may use a local swim vendor and may be reimbursed for up to $200. | No |
Cellular Services | Sunshine Health will connect enrollees to government cell phone service program. For enrollees who do not qualify for a government cell phone program but are in case management, we offer our ConnectionsPlus program which provides a cell phone. | Ages 16 years and older. Must complete Health Quiz for ConnectionsPlus program. One phone per household per lifetime. | Contact your care manager to determine eligibility |
Childcare | One week of childcare or after school care at the YMCA. Benefit for eligible job-or education-seeking members who identified as needing childcare on Health Quiz. | Member must be age 16 and older with a child under 18. Must be enrolled in Care Management. One week of childcare per calendar year. In areas where a YMCA does not exist, members may use a local vendor for up to $150. | Contact your care manager to determine eligibility |
Chiropractic Services | Services provided by chiropractors | Ages 18 and older | Yes |
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. | No |
Computerized Cognitive Behavioral Therapy | Including health focused clinical interview, behavioral observations, and health and behavioral interviews for individual, group and family (with or without the patient) | Ages 21 and older. Unlimited health behavior assessment, reassessment and intervention. | Yes |
Comfort Kit for People Living with HIV | Enrollees living with HIV can get a comfort kit that may include items like a TENS stimulator, hot and cold therapy pack, lidocaine patches or ointment, and/or a fleece blanket. | Must be enrolled in Sunshine Health Power to Thrive HIV Specialty Plan. One per lifetime. | Contact your care manager to determine eligibility |
Dental Kit | One dental hygiene kit per year for pregnant members who complete their NOP. | Ages 13 and older | No |
Digital Care Support for Adults | Digital behavioral health platform that supports adults with anxiety, depression, substance use disorder or schizophrenia | Ages 18 and older | No |
Digital Youth Engagement Tool | Digital tele-behavioral health platform connects teens/young adults with Certified Peer Specialist Mentors | For members ages 13 to 22 after a behavioral health inpatient or emergency hospitalization | 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 and older. No limits. | No |
Durable Medical Equipment (DME) services and supplies | Additional coverage for items not covered under standard benefits, such as, wound supplies, hospital bed and mattresses, insulin pump and infusion pump | Ages 21 and older | Yes, for some equipment and supplies |
Durable Medical Equipment/ Asthma/COPD Supplies | Hypoallergenic bedding up to $100 per year and one (1) high-efficiency particulate air (HEPA) filter vacuum cleaner per lifetime for members diagnosed with asthma or COPD | Must have asthma or COPD diagnosis, be enrolled in Care Management, and complete Health Quiz. | Contact your care manager to determine eligibility |
Educational Benefit | Up to $150 reimbursement with documentation after completion of Health Quiz and Sunshine Health Works Launchpad career assessment | Ages 16 and older. One per lifetime | Contact your care manager to determine eligibility |
Equine Therapy | Provided to members with behavioral health conditions and involves activities with horses | Ages 21 and older. Up to 10 sessions per year. | Yes |
Expanded Primary Care Services | Visits to primary care provider. Visiting a primary care provider can help in maintaining everyday health. | Ages 21 and older. Unlimited. | No |
Expanded Prenatal Visits | Unlimited antepartum and postpartum visits
| Ages 10-59
| No
|
First Year of Life Safe Sleep | One crib per baby per delivery | Must be aged 13 or older. Mother must complete a postpartum visit within 7-84 days. Baby must be enrolled in First Year of Life program, and complete six pediatrician visits within six months. | Yes |
Fresh Funds | $50 per month for pregnant members, up to 6 months post delivery | Members must complete postpartum visit within 7-84 days, be aged 13 or older and be enrolled in Care Management for high risk pregnancy | Contact your care manager to determine eligibility |
Flu Prevention Kit | 1 Flu Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer | Ages 18 years and older. Must be enrolled in Care Management. | Contact your care manager to determine eligibility |
Grocery Benefit | $50 grocery benefit per household for enrollees who identify as food insecure on the Health Quiz | Ages 16 and older. Must be enrolled in Care Management. Limit one per year. | Contact your care manager to determine eligibility |
Healthy Living Benefit | Assistive devices and adaptive aids to help enrollees maintain independence in their homes. Enrollees can select two from the following items: digital scale, home blood pressure cuff, peak flow meter, reachers/grabbers, lumbar pillow, personal fan, clip on lamp, walker bag, or an assistive technology device such as a smart home device (i.e. Amazon Echo). | Ages 21 and older. One per lifetime. | No |
Hearing Services | One hearing aid assessment, fitting, checking, and evaluation every two years; One in-ear monaural hearing aid per calendar year; One hearing aid, all other types, per ear every two years. | Ages 21 and older.
| No |
Housing Assistance | A maximum of $250 per community-based members per year to assist with housing related expenses (rent, utilities). This benefit can only be used after available community resources have been explored at Sunshine Health Connects. | Must be 16 years or older, enrolled in Care Management and be in our MMA or LTC plan. Must complete Health Quiz. | Contact your care manager to determine eligibility
|
Home Allowance | Sunshine Health Mindful Pathways (SMI) and Sunshine Health Power to Thrive (HIV) specialty plan members can receive up to $2,500 per member per lifetime for housing assistance such as rent, utilities or small appliances. | Up to $2,500 per member per lifetime. Ages 21 and older. Must be enrolled in Care Management and complete Health Quiz. This benefit can only be used after available community resources have been explored at Sunshine Health Connects. | Contact your care manager to determine eligibility
|
Home Delivered Meals – Disaster Preparedness | Healthy food delivered to your home during an emergency, such as a natural disaster | 1 kit of 10 shelf stable meals, annually | Yes |
Home Delivered Meals - General | Healthy food delivered to your home for nutritional support | Up to 10 meals per event. Must complete Health Quiz. | Yes |
Home Delivered Meals - Post Transition Meals | Meals delivered to your home after discharge from hospital or nursing facility | No age limit. Unlimited (10 meals per discharge event).
| Yes |
Home Delivered Meals for Enrollees with High-Risk Pregnancy | 266 meals per pregnancy to enrollees who are at least 20 weeks pregnant, active in care management and have a qualifying medical condition | Ages 13 and older. Minimum 20 weeks pregnant, up to four months postpartum. Must be enrolled in Care Management and complete Health Quiz.
| Contact your care manager to determine eligibility |
Home Delivered Meals for People Living with HIV | 168 home-delivered medically tailored meals per year to enrollees living with HIV who are active in care management | Must be enrolled in Sunshine Health Power to Thrive HIV Specialty Plan and complete Health Quiz. Must be enrolled in Care Management. | Contact your care manager to determine eligibility |
Home Health Nursing/Aide Services | Home health care provides individuals with greater independence to remain in their homes and be as self-sufficient as possible. | Ages 21 years and older For acute/short term conditions, services are for a period of 60 days or less. | Yes |
Home Visits by a Social Worker | Home visits by a clinical social worker to assess your needs and provide available options and education to address those needs. Home visits also reduce the need for transportation. | Ages 18 and older. 48 visits per calendar year. | No |
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 or COPD to qualify. Must be enrolled in Care Management. | Contact your care manager to determine eligibility |
Lactation Support | Pregnant members get 24/7 telephonic lactation support by calling 1-855-463-4100 (TTY 1-800-955-8770) |
| No |
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 member 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. Must be enrolled in Care Management. | Contact your care manager to determine eligibility |
Massage Therapy | Medical/clinical massage therapy provided by a massage therapist, physical therapist or chiropractor. | Ages 21 and older. Unlimited as deemed medically necessary. Must be for a specific medical condition or injury, not relaxation or preventive purposes. | Yes |
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 |
Medically Tailored Meals – Congestive Heart Failure | Up to 84 meals for 6 weeks for members with congestive heart failure | Ages 13 and older. Member must be enrolled in case management with a diagnosis of high blood pressure and complete 1 month of active blood pressure monitoring with their case manager and an annual wellness doctor visit. | Contact your care manager to determine eligibility |
Medically Tailored Meals – Diabetes | Up to 84 meals for 6 weeks for members with diabetes | Ages 13 and older. Member must be enrolled in Case Management and complete an annual preventive visit with blood sugar test and one of the following: blood pressure test with primary doctor, diabetic eye exam or urine test for kidney disease with primary doctor. | Contact your care manager to determine eligibility |
Mom Care Bundle | One bundle per pregnancy to support postpartum self-care | Ages 13 and older. Must have completed postpartum visit between 7 and 84 days post-delivery, and be enrolled in Care Management for high risk pregnancy. | Contact your care manager to determine eligibility |
Nursing Facility Transition Assistance | To help families of children living in a nursing facility to bring their child home. The benefit will help children and their families 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. Must be enrolled in Care Management. | Yes |
Nutritional Counseling | A healthy diet can promote weight loss, lower blood pressure and cholesterol and has additional health benefits such as reducing depression and improving sleep. Outpatient visits with a dietician for members. | Ages 21 and older. | No |
Occupational Therapy | Treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house. Occupational therapy can help individuals develop, recover, or maintain meaningful activities of daily living allowing them to be more self-sufficient.
| Ages 21 and older. One evaluation per calendar year. One re-evaluation per calendar year. Up to seven therapy visits per week. Application of casting or strapping two (2) per day, wheelchair evaluation and fitting by a physical therapist – one (1) every three (3) years | Yes, except initial evaluation |
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 |
Up to $600 voucher to become a Peer Support Specialist for members who identify as needing job support on a Pathways to Prosperity screening and complete Sunshine Health Works Launchpad career assessment | Ages 18 and older. One per lifetime. | Contact your care manager to determine eligibility | |
Physical Therapy | Physical therapy aids in pain relief to help individuals function, move, and maintain a better quality of living. 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. Application of casting or strapping two (2) per day, wheelchair evaluation and fitting by a physical therapist – one (1) every three (3) years | Yes, except initial evaluation |
Ready for Baby Bundles | Two bundles per delivery: Bundle 1: diapers, wipes, diaper cream, nasal saline, humidifier, rectal thermometer, gas drops, pacifiers, swaddle, noise machine, infant health education sheet (when to seek medical help) Bundles 2-6: diapers in customizable sizes, wipes and diaper cream | Child must be enrolled in FYOL program and complete two Well Child Visits to get the first bundle and complete an additional 4 Well Child Visits to get the second bundle. Child age must be birth -15 months. One per baby, per delivery. | Yes |
Remote Patient Monitoring | Remote patient monitoring program to support a healthy pregnancy | Must be aged 13 or older and enrolled in Care Management for high-risk pregnancy | Contact your care manager to determine eligibility |
Respiratory Therapy | Respiratory illnesses such as chronic obstructive pulmonary disease (COPD) and asthma can have a severe impact on activities of daily living | Ages 21 and older. One initial evaluation and re-evaluation per calendar year. One respiratory therapy visit per day. | Yes |
Respite Care | Short-term relief for caregivers of enrollees 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 |
Speech Therapy | Speech Therapy increases self-esteem by allowing individuals to better communicate their thoughts and feelings and gain more confidence in social situations, decreasing social isolation, loneliness, anxiety, and depression. 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 |
Swimming Lessons (children only) | Children under 21 years old can get group swim sessions at the YMCA. Show member ID card at the YMCA front desk to sign up. | One group session (up to 8 lessons) per calendar year. In areas where a YMCA does not exist, members may use a local swim vendor and may be reimbursed for up to $200. | No |
Tattoo Removal | Benefit for members who have completed their Pathway to Prosperity screening, demonstrated workforce need and completed Sunshine Health Works Launchpad career assessment. | One per lifetime; $500 limit, Ages 18–26 | Contact your Care Manager to determine eligibility
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Transportation Services to Non-Medical Appointments/ Activities | Up to three trips a month for non-medical purposes such as shopping or social events. Trips are limited to member’s home county/local area or up to 30 miles one way. | Ages 18 and older. Must not have another means of transportation to qualify. | No |
Tutoring | Twelve (12) tutoring sessions to aid in removing educational barriers | Up to 2 hours of tutoring time per session; maximum of 24 hours per year. Ages 16 and up. | Contact your Care Manager to determine eligibility
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Vision Services | One routine eye exam per year, prescription eyeglasses (one pair of frames per year), and multiple types of contact lenses (six months’ supply) | Ages 21 and older | No |
Vital Records Support | $50 per year for copies of personal documentation, such as driver’s license or birth certificate | Ages 16 and older. Member must have completed their Health Quiz. | Contact your Care Manager to determine eligibility
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Waived Copayments | Waiving copayments reduces financial burden on individuals. All services, including behavioral health. | Ages 21 and older | No |
Welcome Baby! Bundle | One benefit 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. | Ages 13 and older. Must complete NOP, three prenatal visits, and either be due to deliver within the next 12 weeks, have delivered within the past 30 days, or have a baby who was in the NICU within the last 90 days. | Contact your Care Manager to determine eligibility |
YMCA Membership | For individuals or family of four. Includes access to free standing YMCA facilities and Y360 virtual platform. Maximum benefit of $150 per year. Member must visit the facility or login to Y360 at least once a month to keep membership. | Ages 16 and older. Caregiver, parent or guardian must be present for ages 16 and 17. Show member ID card at the YMCA front desk to sign up. | No |