CMS Health Plan Transition

Starting October 1, 2026, Molina Healthcare will operate the Children’s Medical Services (CMS) Health Plan.

It is important for you to know that your provider contract with Sunshine Health will not transfer to Molina. You must contract directly with Molina to continue serving CMS Health Plan members after the Continuity of Care period. 

Providers are encouraged to monitor updates and prepare for outreach from Molina Healthcare. Healthcare providers should not cancel appointments with current patients. Additional information will be shared as it becomes available. 

Frequently Asked Questions 

What’s changing?

• Starting October 1, 2026, Molina Healthcare will operate CMS Health Plan. 

• Providers must contract with Molina Healthcare to continue serving CMS Health Plan members after the Continuity of Care period. 

What’s staying the same?

• Membership will transfer from Sunshine Health to Molina Healthcare. 
• CMS Plan will continue under the same name.
• Existing prior authorizations will be provided to and honored by Molina through the Continuity of Care period. 

What can I expect before the transition?

• Molina Healthcare is building its network. Providers interested in joining can initiate the process on Molina’s website.

• More information will be shared as transition details are finalized. 

Network Exception Requests for BA services

Effective September 4, 2026, Sunshine Health will no longer review new CMS Health Plan Network Exception Requests for BA services due to the transition of the CMS Health Plan to Molina Healthcare effective October 1, 2026.

Please note that all CMS Health Plan Network Exception Requests received on or before September 3, 2026, will be reviewed. Network Exception Requests for Sunshine Health MMA, Child Welfare (CW), and Serious Mental Illness (SMI) members will continue to be reviewed through the standard process.

Providers seeking additional information about the transition or looking to join Molina’s network should visit Molina’s CMS Health Plan provider web page.

Authorization, Appeals and Claims Guidance

As CMS Health Plan transitions from Sunshine Health to Molina Healthcare effective October 1, 2026, providers should use the guidance below when submitting authorization requests, coordinating concurrent review, filing appeals and submitting claims.

The appropriate health plan is determined by the service start date, date of service (DOS), or inpatient admission date, depending on the type of request.

Prior Authorization

Authorization requests for services beginning prior to October 1, 2026, should continue to be submitted to Sunshine Health through the Availity Portal or fax 1-866-796-0526.

Inpatient Concurrent Review

For members who are admitted prior to October 1, 2026, and are expected to remain inpatient on or after October 1, concurrent review should continue to be coordinated through Sunshine Health.

Sunshine Health will remain responsible for concurrent review for the inpatient stay when the admission occurred prior to October 1, 2026, including stays with an estimated discharge date on or after October 1, 2026.

Authorization Appeals

The process for authorization appeals depends on whether the service has already been rendered.

• Pre-Service Appeals: If the service has not yet been rendered and will occur on or after October 1, 2026, providers should submit a new authorization request to Molina rather than continuing the pre-service appeal process with Sunshine Health.
• Post-Service Appeals: If the service was rendered prior to October 1, 2026, the post-service appeal should continue to be submitted to Sunshine Health.

Professional and Non-Inpatient Facility Claims

Professional and non-inpatient facility claims should be submitted based on the Date of Service (DOS).

Claims That Span September 30, 2026, and October 1, 2026

Claims containing dates of service both before and after October 1, 2026, must be split based on date of service.

For example, if services were provided from September 29, 2026, through October 3, 2026:

• Services dated September 29–30, 2026, should be submitted to Sunshine Health.
• Services dated October 1–3, 2026, should be submitted separately to Molina.

Providers should not submit a single professional or non-inpatient facility claim that includes dates of service spanning both health plans.

Inpatient Facility Claims

Inpatient facility claims are based on the member's admission date.

When a member is admitted prior to October 1, 2026, and discharged on or after October 1, 2026, the entire inpatient facility claim should be submitted to Sunshine Health.

The inpatient claim should not be split between Sunshine Health and Molina Healthcare.

For members in residential treatment or placement settings, Sunshine Health will cover services through September 30, 2026, and Molina Healthcare will cover services beginning October 1, 2026, and later.

Please review service, admission, and discharge dates carefully before submitting requests or claims to help avoid unnecessary processing delays during the transition.

Questions? 

Talk to your Sunshine Health provider engagement account manager or contact Provider Services at 1-844-477-8313. 

View updates from the ⁠Agency for Health Care Administration.