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Sunshine Health Will Operate Children’s Medical Services Health Plan!

 

Your child’s Medicaid plan, Children’s Medical Services Health Plan, operated by WellCare, will soon be operated by Sunshine Health! This is good news.

Your child will keep the same great benefits. In most cases, your child’s care manager, doctors and prescriptions will stay the same. Plus, the provider network is growing to give you even more choices.

Beginning Oct. 1, 2021, Sunshine Health will operate Children’s Medical Services Health Plan. In the weeks before Oct. 1, 2021, your child will receive a new Member ID card in the mail.

You do not need to do anything.

Your Member Services phone number will remain the same: 1-866-799-5321.

 

What is changing on Oct. 1, 2021

New Member Rewards Program: Your child will be automatically eligible for Sunshine Health’s member rewards program that pays dollar rewards for certain healthy behaviors. It’s called My Health Pays®. For example, earn $20 just by completing your child’s Tdap and meningococcal vaccines. See the full list of rewards below.

New Specialty Pharmacy Provider: AcariaHealth provides Sunshine Health’s specialty medications. If your child needs these, some medicines may be able to be shipped to your home. Learn more below.

New Easy Order OTC: It’s easy to use your $25 per month per household over-the-counter (OTC) benefit. Download the Envolve OTC mobile app. Browse and select products shipped to your home, all from your phone. Learn more below.

New TTY Relay Services Phone Number: While the Member Services number is not changing, the TTY number for Relay Services will change to 1-800-955-8770. This number helps people who are blind/low vision and/or deaf/hard of hearing communicate with an assistive device.

Expanded Member Services Hours: Starting on Oct. 1, 2021, you will have an extra hour to call the health plan to ask questions about your child’s benefits. The call center will now be open from 8 a.m. to 8 p.m. Monday through Friday!

New Vision Provider: On Oct. 1, 2021, your child’s new vision provider will be Envolve Vision. Please call Envolve Vision at 1-833-705-1354 (TTY 1-800-955-8770). You can also call your child’s care manager directly or at 1-866-799-5321 (TTY 1-800-955-8770) for help with these services.

New Dental Provider (Florida KidCare Only): On Oct. 1, 2021, your child’s new dental provider will be Envolve Dental. Please call Envolve Dental at 1-833-705-1354 (TTY 1-800-955-8770). You can also call your child’s care manager directly or at 1-866-799-5321 (TTY 1-800-955-8770) for help with these services.

 

Continuity of Care

During this change period, please keep all your child’s scheduled doctor appointments and continue working with your child’s care manager. Your child will not experience any break in care. WellCare will continue providing your healthcare coverage until Sunshine Health begins operating Children’s Medical Services Health Plan on Oct. 1, 2021. Your child can keep getting services that WellCare already approved. Sunshine Health will pay for these approved services. Most WellCare providers are in the Sunshine Health provider network. If the provider is not in Sunshine Health’s network, your child can keep going to that provider for up to 120 days. This 120-day period is called the Continuity of Care Period. After 120 days, your child will need to get services through a Sunshine Health network provider.

 

Quality Healthcare

Learn about the Quality Program below. Get details on your child’s rights as a health plan member. Learn about filling prescriptions, appeals, grievances, complaints, knowing if a service is covered/denied, new services and more.   


What is changing?

Your child’s health plan, Children’s Medical Services Health Plan, operated by WellCare, will be operated by Sunshine Health beginning Oct. 1, 2021. 

Will my child lose benefits when Sunshine Health begins operating Children’s Medical Services Health Plan?

No. Your child will keep all the benefits they currently have. In most cases, your child’s care manager, doctors and prescriptions will stay the same. Your child will not experience any break in care.

Why is my child getting a new ID Card?

Your child’s new ID card will reflect that Children’s Medical Services Health Plan is operated by Sunshine Health. You should receive this new ID card in September 2021.

Do I need to keep my child’s current member ID card?

Yes. Keep your child’s current member ID card until Oct. 1, 2021. After that, please use the new Member ID card you will receive in the mail in September 2021.

What do I have to do because of this change?

You do not need to do anything. Your child’s health plan will automatically become operated by Sunshine Health on Oct. 1, 2021. Your child’s benefits will stay the same.

Who can I call with questions?

Before Oct. 1, 2021, call Children’s Medical Services Health Plan Member Services: 1-866-799-5321 (TTY 711) Monday-Friday, 8 a.m. to 7 p.m. Eastern. After Oct. 1, 2021, our phone number will stay the same, but we will be open another hour to serve you, until 8 p.m. Eastern.

Will there be any change in how you protect my privacy?

No. Your privacy is important to us. You have rights when it comes to protecting your health information, such as your name, plan identification number, race, ethnicity and other things that identify you. We will not share any health information about you that is not allowed by law.

 

What is the My Healthy Pays Program?

The My Health Pays Program promotes healthy behaviors. It includes activities that can help your child live a healthier life. Starting Oct. 1, 2021, your child can earn rewards for completing them!*

Get a reloadable debit or gift card for healthy activities like:

  • Getting recommended wellness checkups for your child
  • Working with your child’s providers to manage illness (like diabetes)
  • Participating and completing activities within the Smoking Cessation, Weight Loss or Substance Use Disorder programs

* Rewards cannot be transferred. If your child leaves our plan, rewards may not be received.

My Health Pays Programs

We offer programs to help keep your child healthy and help your child live a healthier life (like losing weight or quitting smoking). We call these healthy behavior programs. Your child can earn rewards while participating in these programs. The plan offers the following programs:

Additional Incentives

Focus Area

Activity Criteria

Incentive Value

Tobacco Cessation Health Coaching Sessions

Age 10 and up. Must submit a consent form signed by member’s parent/guardian, verbally pledge to stop tobacco use and complete all four sessions within six months of the first session. $5 reward after each completed session.

Up to $20

Weight Loss Health Coaching Sessions

Age 10 and up. Must submit a consent form signed by member’s parent/guardian, verbally pledge to lose weight within 30 days and complete six sessions within six months.

 $20

Substance Use Health Coaching

Age 12 and up. Complete three coaching sessions with a Care Manager in three months. Enrollment in Case Management and signed consent form by member’s parent/guardian are required.

$10

Comprehensive Diabetes Care

Age 13-20. Complete both HbA1c test and retinopathy screening (dilated eye exam) once in the calendar year

$25

Post-Behavioral Health Admission Follow up Visit

Earn rewards for attending an outpatient follow up appointment with a behavioral health provider within seven days after discharge from an inpatient facility

$20

Notification of Pregnancy Form (First trimester)

Age 12-20 years. Complete and sign a Notification of Pregnancy form within first trimester

$20

 

Prenatal Care

 

Complete a prenatal visit

$20

 

Children’s Health

Focus Area

Activity Criteria

Incentive Value

Immunizations for Adolescents (Combo 1)

Ages 10-13. Complete both Tdap and meningococcal vaccines.

$20

Annual Well Child Visit Ages 0-30 months. Annual Well Child Visit with a PCP, one per year $10
Annual Well Child Visit

Age 15-20. Annual Well Child Visit with a PCP, one per year

$20

Please remember that rewards cannot be transferred. If your child leaves the plan for more than 180 days, your child may not receive the reward.

My Health Pays reward dollars are added to the rewards card after we process the claim for each activity your child completes.  If your child is earning the first reward, a My Health Pays® Visa® Prepaid Card will be mailed to you.

This My Health Pays Rewards Visa Prepaid card is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. The Bancorp Bank; Member FDIC. Card cannot be used everywhere Visa debit cards are accepted.

 

Children’s Medical Services Health Plan, operated by Sunshine Health, has a pharmacy program. Your child’s doctor, or specialist, may give a prescription for medicine. You must get the prescription filled at a pharmacy that is part of the Sunshine Health pharmacy network.

The Preferred Drug List (PDL) is a list of covered medicines. Your child’s doctor will use the PDL to choose the best medicine to treat them. This list is reviewed by doctors and pharmacists regularly to make sure only the safest and most effective drugs are on the list. Please ask your child’s doctor or pharmacist if you have any questions about their medicines. Always ask the doctor if your child’s prescription is covered by Children’s Medical Services Health Plan. If not, then ask the doctor to change it to a medicine that is covered. This will help you get your child’s prescription filled the first time you take it to the pharmacy.

We cover brand name and generic drugs. Generic drugs have the same ingredients as brand name drugs, but they are often cheaper than brand name drugs. They work the same. Sometimes, we may need to approve using a brand name drug before your child’s prescription is filled.

Specialty Medicines

Some drugs are not available at a local pharmacy. These drugs are supplied by a specialty pharmacy provider. These drugs may need prior approval before your child’s prescription can be filled. The pharmacy will tell your child’s doctor if the drugs have to be supplied by a specialty pharmacy and a prior approval is needed.

Sunshine Health partners with AcariaHealth to provide specialty drugs. These are drugs that treat complex conditions. They require extra support to make sure they are used correctly. You will be offered the option to select a different specialty pharmacy for your child by mail, after the initial specialty medication is filled. 

 

Shop over the counter from your phone

Starting Oct. 1, you can order your child’s over-the-counter health and wellness products through the Envolve OTC Mobile App.

  • Order from the app, no need to call.
  • Browse and buy eligible products.
  • Ship right to your home.
  • Check your balance and use available funds.
  •  Get reminders to use the funds before they expire.
  • View order history and current order status.

Download the app on Oct. 1 from the Apple App Store or Google Play. Register and create an account.

 

Get the Most from Your Child’s Coverage

Your Child Deserves Quality Healthcare. And you also deserve to have the information you need to get the most from your child’s coverage. Goals for quality are set and reviewed by CMS Health Plan to make sure your child gets the proper care.

This information is part of a Quality Program designed to improve the services and care your child gets. It provides details about the coverage and services available. 

Contact Member Services to learn more about the Quality Program.

Know Your Rights

Being a member means there are things you should expect from CMS Health Plan. These are some of your rights:

  • Your child should be treated with courtesy and respect
  • You should be able to get a copy of your child’s medical record
  • You should know your child’s medical data will be kept private. There are policies in place to guard health records and protected health information.

It’s also important to know what you can do to get the most from your coverage:

  • Ask questions if you don’t understand your rights
  • Be sure to keep your child’s scheduled appointments
  • Keep your child’s Member ID Card with you so you have it at appointments
  • Tell your child’s doctor if your child has gotten care in an emergency room.

Getting the Care Your Child Needs

PRIMARY CARE PROVIDER (PCP) 

The PCP is the doctor your child will see for routine checkups and care. The PCP will help find other types of healthcare providers if your child needs one. You can also search Find-a-Provider on the CMS Health Plan website.

CHILDREN AND TEENS 

As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call CMS Health Plan if you need help finding an adult provider.

MAKING APPOINTMENTS 

You should be able to schedule an appointment with your child’s PCP and get medical care when your child needs it. It may take a little longer to get in to see certain other types of providers, like specialists. Call CMS Health Plan if you can’t get an appointment in a timely manner.

GETTING PRESCRIPTIONS FILLED 

Your child should get high quality medications and the right treatment for his or her conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on the CMS Health Plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to a doctor or pharmacist to review the PDL and answer questions about your child’s medications.

KNOWING IF A SERVICE IS COVERED 

The Utilization Management (UM) Department looks at your child’s health records and may also talk with your child’s doctor to decide if a service he or she needs is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:

  • If the service is medically necessary
  • If the service works well
  • If the service is right for your child

NEW SERVICES AND TECHNOLOGY 

New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by CMS Health Plan. Your child’s plan covers care that is medically necessary. Not every new medical service is covered for all members.

IF A SERVICE IS DENIED 

If a service is denied, you have the right to appeal that decision. They will be sent a letter explaining how to make an appeal. All appeal requests are decided according to the request, condition and benefits.

Get More Information

Starting on Oct. 1, 2021, the Member Handbook will be a great source for information about coverage and benefits. It also lists important phone numbers.

Contact Member Services for additional help at 1-866-799-5321 (TTY 1-800-955-8770). Translation services are available if you need them.

Starting on Oct. 1, 2021, Contact Member Services to get:

  • A paper copy of the Member Handbook, Privacy Notice or anything on the CMS Health Plan website
  • Help finding a doctor and making an appointment
  • Help speaking with your child’s care manager
  • Help with an appeal for a service that’s been denied
  • Help with a ride to your child’s appointment

The CMS Health Plan website will also have a lot of helpful information. Visit it starting Oct. 1, 2021 to find the Member Handbook, Find-a-Provider tool, and the Preferred Drug List.

Creating an online member account is free and easy. With it, you can:

  • Find or change your child’s PCP
  • Request a new Member ID Card or print a temporary ID Card
  • View and update your child’s personal information

You can also send a message directly to CMS Health Plan from a member account.