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Q1 2025 Connected In Care

 

Sunshine Health now covers Behavior Analysis (BA) services for Medicaid members up to 20 years of age who require medically necessary BA services.

To help BA providers with this transition, we put together an array of resources to help them navigate the health plan processes and offer the best care possible to their patients, our members.

For members ages 21 years and older, BA services are available via the iBudget waiver.

BA Resources

 

  • December 11, 2024 BH & ABA Provider Town Hall: Learn more by viewing this recorded provider town hall session.
  • AHCA: The state has more information and resources for BA providers. 

BA Authorizations

  • Providers do not need to do anything if an existing authorization is in place. Those authorizations will be extended through the 120-day Continuity of Care (CoC) period.
  • Providers should continue all medically necessary services that were previously authorized.
  • For existing authorizations with approaching end dates, providers can submit requests via the Secure Provider Portal or via Availity Essentials.

For 2025, Sunshine Health renamed our existing health plan products, introduced a new health plan for members diagnosed with HIV/AIDS, and offered new and improved benefits for our members.

New Health Plan Names

  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP): The new name for our Child Welfare Specialty Plan product, which serves the physical and behavioral healthcare needs of children in or adopted from Florida’s child welfare system.
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI): The new name for our Serious Mental Illness product, which serves the behavioral health needs of our members by providing coordinated behavioral, medical and pharmacy services.

New Health Plan

  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV): This new health plan serves persons diagnosed and living with HIV/AIDS with a focus on the entire continuum of care for persons with HIV, from accelerating access to treatment and antiretroviral medicine to engaging with members to preserve quality of life.

New Benefits

Sunshine Health now offers new benefits, including three non-medical rides, a $50 OTC benefit, caregiver swimming lessons and more.

Learn more about Sunshine Health’s new offerings in 2025

Vendor Changes

The best way to keep track of which vendors are partnering with Sunshine Health to offer services to our members is to visit our updated Vendors page.

Ambetter Health partnered with Evolent (formerly New Century Health), a comprehensive cardiovascular quality management company, to implement a new prior authorization program. The Evolent Cardiology Solution Program is designed to help providers easily and effectively deliver quality patient care.

The program launched on April 1, 2025. Invasive cardiovascular procedures and services rendered in a physician’s office, outpatient hospital, and ambulatory or inpatient setting now require prior authorization from Evolent. This applies to all Ambetter Health members ages 19 years and older. Ambetter Health will directly manage cardiology services for members ages 18 years and younger.

TurningPoint no longer provides cardiology services for Ambetter Health members. TurningPoint authorizations issued before April 1, 2025, will remain in effect until the authorization end date.

Learn more about the Evolent Cardiology Solution Program

Ambetter Health started administering authorizations for Ear, Nose and Throat (ENT) services for Ambetter Health members on May 1, 2025. These services were previously provided by TurningPoint.

TurningPoint authorization approvals issued before May 1, 2025, are effective until the authorization end date. Please submit prior authorization requests via the Secure Provider Portal.

Learn more Ambetter Health ENT Authorizations

Sunshine Health has streamlined our Registered Behavior Technician (RBT) credentialing requirements based on your feedback.

The new process will minimize administrative burden and improve provider loading times. Here are the updated requirements to become a participating RBT with Sunshine Heath.

Learn more about RBT credentialing requirements

Sunshine Health wants to make Private Duty Nursing (PDN) and Family Home Health Aides (FHHA) providers aware of published policy changes made by the Agency for Health Care Administration (AHCA).

The updated policy affects providers that render PDN and FHHA services to eligible

Medicaid recipients under the age of 21 years who require medically necessary PDN and/or FHHA services.

Sunshine Health put together a PDN/FHAA policy tip sheet and Frequent Asked Questions (FAQ) to help providers understand AHCA’s new policy.

Sunshine Health has launched a new Provider Enrollment Requests web page that has simplified how providers can add new practitioners or facilities to their existing Sunshine Health contract.

This new system offers:

  • Real-time guidance that walks providers through each step of our credentialing and enrollment processes
  • Automated checks to ensure everything is complete before submission
  • A clearer, streamlined and straightforward process that saves time

Learn more about the new Provider Enrollment Requests web page

Sunshine Health has online resources to help providers adhere to the standards for scheduling appointments for medical services and behavioral health services set by the Agency for Health Care Administration (AHCA). Those standards are designed to help providers and their staff provide the best care possible to your patients, our members.

Visit Manuals, Forms and Resources and scroll down to Standards for Appointment Scheduling to find the health plan standards you need. Providers can also access each health plan’s appointment standards directly:

Throughout the yar, Sunshine Health offers virtual Clinical Documentation Improvement (CDI) webinars to help providers and staff improve their coding and documentation to comply with regulatory requirements. These training sessions are focused on the 2025 Model ICD-10 and CMS ICD-10 Resources.

Providers can register for all the sessions that interest them or fit their schedules. The benefits for providers include:

  • Learn best practices for documenting a member’s medical record
  • Understand different principles for documenting and coding
  • Enhance applicable Appointment Agendas submitted to the health plan
  • Get an overview of Risk Adjustment and Hierarchical Condition Categories

Register now for CDI webinars

Provider Incentives

Sunshine Health offers providers a $20 incentive for every member who receives healthcare services after hours. Our goal is to improve members’ access to healthcare, and an effective way to do that is for providers to offer services to their patients outside of their regular office hours.

What is considered after hours?

  • Healthcare services rendered from 5 p.m. to 8 a.m. Local Time
  • All weekends
  • All holidays
  • After-hours telehealth services are included

Learn more about after-hours availability incentives

Providers who complete a Screening, Brief Intervention, and Referral to Treatment (SBIRT) assessment are eligible for an additional $50 reimbursement per member, per screening. To learn more, visit Enhanced Payments for SBIRT Assessments.

Sunshine Health’s Enhanced Payment Program is in addition to the compensation arrangement in the participation agreement in our provider network, as well as other health plan incentive programs that providers participate in.

Learn more about enhanced payments for SBIRT

Sunshine Health is offering an incentive to appropriately trained Obstetrician-Gynecologists (OB/GYN) and Behavioral Health providers: They can receive an additional $100 per claim filed per pregnant member for Medication Assisted Treatment (MAT) services.

MAT is the use of medications, counseling and behavioral therapies to treat substance use disorders. This is a “whole patient” approach to treat addiction. MAT is not a standalone treatment, but a part of other wraparound services to help generate the best outcome for patients. Self-paced, online MAT training is also available to providers.

Learn more about the MAT Services incentive

Sunshine Health is offering additional reimbursement to providers who submit detailed claims or encounters using Social Determinant of Health (SDOH) ICD-10-CM Z Codes.

Z Codes represent factors that influence health status and any contact with health services that may be recorded as diagnoses. Codes Z-55 through Z-65 identify non-medical factors that may influence a member’s health. To learn more about benefits and barriers to utilizing Z Codes, we encourage providers to reference this Quick Guide to SDOH ICD-10 Codes (PDF).

Learn more about the SDOH Bill Above Program

Sunshine Health has updated our Electronic Visit Verification (EVV) For Home Health Providers web page for Home Health providers to share the latest guidance and procedures.

The health plan collaborates with HHAeXchange (HHAX) and its electronic visit verification (EVV) technology to enhance member service and comply with state requirements.

The HHAX portal remains Sunshine Health’s method for communicating authorization information and billing to providers.

Learn more about Electronic Visit Verification (EVV) For Home Health Providers

Sunshine Health offers training webinars to help providers learn more about one of healthcare’s most widely used performance measures: Healthcare Effectiveness Data and Information Set (HEDIS).

HEDIS performance measures are developed by the National Committee for Quality Assurance (NCQA) and are used by regulators to evaluate the effectiveness of healthcare plans, providers and practitioners.

Sunshine Health’s HEDIS 101 webinars are separated by products, but providers can register for as many training sessions as you wish.

Register now for HEDIS 101 training webinars

Sunshine Health has some tips to help providers with W-2 (1099) and W-9 tax forms for tax season and for incentive payments. For the latest guidance, instructions and tax forms, visit our tax season tip sheet.

Sunshine Health offers an array of benefits and resources to support members from pregnancy to birth and beyond. Check out our updated Maternity Benefits and Member Supports web page for the latest benefits, special programs and healthy rewards for new mothers and their children.

Children’s Medical Services (CMS) Health Plan Wrap Up

Medication adherence is crucial to the health of our youngest members. That’s why CMS Health Plan alerts providers when their patients may not be refilling or adhering to their prescriptions.

The health plan reviews pharmacy claims data to determine whether children diagnosed with conditions such as asthma, diabetes, epilepsy, sickle cell disease or a behavioral health condition may not be refilling or adhering to their prescriptions. This can result in increased hospitalizations for some members.

Adherence can be defined as a member filling their prescriptions for a diagnosis at least 80% of the time over a 6-month period. Please look for communications from the health plan regarding your patients.

CMS Health plan monitors patients with chronic conditions to ensure they’ve been prescribed the medications they need to treat and manage their conditions.

The health plan uses medical claims data to determine whether patients diagnosed with asthma, diabetes, epilepsy, sickle cell disease or a behavioral health condition have received prescriptions for their conditions on file.

To optimize patient care, please evaluate these patients’ therapies:

  • Asthma: Please provide all patients with a reliever inhaler, even those with frequent symptoms.
  • Behavioral Health: Consider prescribing medication or therapy for patients who have had up to two hospitalizations in the last six months.
  • Diabetes: Consider prescribing diabetic medication for patients if their Hemoglobin A1c is not at goal.
  • Epilepsy: Consider prescribing anti-epileptic drug therapy to decrease seizure frequency and prevent risk of seizure recurrence, as recommended by the American Academy of Neurology.
  • Sickle Cell Disease: Consider prescribing hydroxyurea, a mainstay drug therapy for sickle cell disease recommended by the National Heart, Lung and Blood Institute. If a patient is intolerant or cannot use hydroxyurea, please consider Endari or Adakveo.