Benefits Overview

Your Plan Benefits: Managed Medical Assistance Services

The table below lists the medical services covered by Sunshine Health. Remember, you may need a referral from your 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 state 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 1-866-796-0530.

NOTE: Services marked with an asterisk (*) are behavioral health in lieu of services. This means they are optional services you can choose over more traditional services based on your needs.

Except for emergency care, Sunshine Health must prior authorize any services provided by an out-of-network provider and any elective inpatient admissions.

You can also view more information about Sunshine Health in our Member Handbook (PDF).

All services must be medically necessary. Your Primary Care Provider will work with you to make sure you get the services you need. These services must be given by your Primary Care Provider or by another provider that your Primary Care Provider refers you to.

Some services may:

Have coverage limits.
Need a doctor’s order.
Need prior approval.

(Some Medicaid members may not have all the benefits listed.)

Your Plan Benefits: Managed Medical Assistance Services
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 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) to 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: 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 - 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 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
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. 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: Hemodialysis treatments Peritoneal dialysis treatments	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 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 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 years who have developmental delays and other conditions.	Covered as 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 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: 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
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: 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.
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 healthcare for people with mental illnesses.	Covered as medically necessary.	No
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: Out-of-state travel Transfers between hospitals or facilities Escorts when medically necessary	Yes, for trips 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
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 health care 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 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 reentering 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: Respiratory testing Respiratory surgical procedures Respiratory device management	Yes, for some services.
Respiratory Therapy Services	Services for 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
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 for 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 to 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
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 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 Plan Benefits: Expanded Benefits
Service	Description	Coverage/ Limitations	Prior Authorization
Acupuncture	Insertion of thin needles through skin to treat pain, stress and other conditions. Acupuncture is used to treat chronic 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
Behavioral Health Integration/Collaborative Care	Unlimited visits with Collaborative Care teams for whole health. Unlimited visits for members 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
Camp Scholarship	$150 voucher to attend children’s camp	Ages 4-18. Must be enrolled in Care Management and have completed annual wellness exam.	Contact your care manager to determine eligibility.
Care Grant	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	Voucher or reimbursement for caregivers to take group swimming lessons. Includes up to 8 lessons from a local YMCA, if available.	Ages 18 years and older. In areas where YMCA doesn’t exist, members may use a local swim vendor.	No
Cellular Services	Sunshine Health will connect enrollees to government cell phone service program.	Ages 16 years and older. 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.	Contact your care manager to determine eligibility.
Childcare	Voucher for eligible job-seeking members who identify as needing childcare on Pathways to Prosperity screening.	$150 limit. Must be age 16 and older. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Chiropractic Services	Services provided by chiropractors.	Ages 18 years 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 if medically necessary.	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 years and older. Unlimited.	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.	Contact your care manager to determine eligibility.
Dental Kit	One dental hygiene kit per year for pregnant members.	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 (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 10 years and older.	Yes, for some equipment and supplies.
Durable Medical Equipment/ Asthma/COPD Supplies	Unlimited hypoallergenic bedding and one (1) high-efficiency particulate air (HEPA) filter vacuum cleaner for members diagnosed with asthma or COPD.	Must have asthma or COPD diagnosis. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Educational Vouchers	$150 voucher after completion of Sunshine Health Pathway to Prosperity Screening and Sunshine Health Works Launchpad career assessment.	Ages 16 and older.	Contact your care manager to determine eligibility.
Equine Therapy	Provided to members with behavioral health conditions and involves activities with horses.	Ages 21 years and older. Up to 10 sessions per year.	Yes
Expanded Prenatal Services	Unlimited antepartum and postpartum visits One breast pump, hospital grade rental One manual breast pump	Ages 10-59 Ages 10-59 One every 2 calendar years; Ages 10-59	No Yes No
Expanded Primary Care Services	Visits to primary care provider. Visiting a primary care provider can help in maintaining everyday health.	Ages 21 years and older. Unlimited.	No
Flu Prevention Kit	1 Flu Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer	Ages 18 years and older. Eligible for the first 1,000 members who receive a flu vaccine. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Grocery Benefit	$50 food voucher per household per year for enrollees who identify as food insecure on Pathways to Prosperity screening.	Ages 16 and older. Must be enrolled in Care Management.	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	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. One hearing aid assessment, fitting, checking, and evaluation every two years; One in-ear monaural hearing aid per ear every two years; One hearing aid, all other types, per ear every two years.	No
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. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Home Allowance	Sunshine Health Mindful Pathways and Sunshine Health Power to Thrive specialty plan members can receive up to $2,500 per member per lifetime for housing assistance.	Up to $2,500 per member per lifetime. Ages 21 and older. Must be enrolled in Care Management.	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 emergency meal kit annually	Yes
Home Delivered Meals - General	Healthy food delivered to your home for nutritional support.	Up to 10 meals per event	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 who are Pregnant	266 meals to enrollees who are at least 20 weeks pregnant, active in care management and have a qualifying medical condition.	Ages 13 and older. Up to four months postpartum. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Home Delivered Meals for People Living with HIV	168 home-delivered medically tailored meals 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 HRA. 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 years and older 48 visits per calendar year	Yes
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.
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. Must be enrolled in Care Management.	Contact your care manager to determine eligibility.
Massage Therapy	Massage of soft body tissues to help injuries and reduce pain. Massage of soft tissues can improve circulation, decrease pain and muscle tightness, improve work of the immune system, and improve sleep.	Ages 21 years and older Unlimited as deemed medically necessary.	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
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. 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 years 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
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 and complete Sunshine Health Works Launchpad career assessment.	Ages 18 and older. One per lifetime.	Contact your care manager to determine eligibility.
Pet Therapy	Provided to members with behavioral health conditions and involves activities with trained animals.	Ages 21 years and older. Unlimited as deemed medically necessary.	Yes
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.
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 years and older. One initial evaluation and re-evaluation per calendar year. One 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. Member must be enrolled in Care Management.	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 years 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 3-minute sessions per calendar year.	Yes, except initial evaluation.
Swimming Lessons (children only)	Children under 21 years 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	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, Age 18 – 26.	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. 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 12 sessions annually. Ages 16 and up. Must be enrolled in Care Management.	Contact your Care Manager to determine eligibility.
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 annual reimbursement for copies of personal documentation, such as driver’s license or birth certificate.	Ages 16 and older. Member must have completed their Pathway to Prosperity screening.	Contact your Care Manager to determine eligibility.
Waived Copayments	Waiving copayments reduces financial burden on individuals. All services, including behavioral health.	Ages 21 years 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 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. Must be enrolled in Care Management.	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 at least once a month to keep membership.	Ages 18 and older. Caregiver, parent or guardian must be present for ages 17 and 16. Members under 16 are only eligible if their parent or guardian is a Sunshine Health member.	No

Benefits Overview

Your Plan Benefits: Managed Medical Assistance Services

Your Medicaid Benefits

Your Medicaid Expanded Benefits