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From the Start: Sunshine Health, AHCA Support Maternal Care

From the Start logo 

Sunshine Health is playing a critical role supporting From the Start, the Agency for Health Care Administration program to elevate maternal care across Florida and improve health outcomes for pregnant women and their children.

From the Start aligns the services and programs offered by Statewide Medicaid Managed Care (SMMC) Programs across the state so that all health plans serving Floridians provide the same enhanced, evidence-based care to improve prenatal and postnatal outcomes.

Elevating this kind of care reduces the health risks and complications that can affect both mother and child before, during and after pregnancy.

Sunshine Health’s goal is to work with our providers to support the wellbeing of our members throughout their pregnancy journey and ensure a healthy start for Florida’s newest families.

Learn more about how Sunshine Health is supporting AHCA’s From the Start program to improve birth outcomes for Florida Medicaid families.

Maternal health providers can support that goal and protect the health of their patients through the following programs.

Note: Providers with capitated agreements are not eligible for incentive programs.

Maternal Incentive Programs

C-Section Birth Incentive for Obstetricians (OBs) Incentive

Goal: C-section births can be a life-saving procedure for mothers and their newborns when medical conditions complicate labor and delivery. But there are concerns that this procedure has become overused, and it comes with major risks: hemorrhaging, infections, uterine scarring, infertility, and future pregnancy problems. Sunshine Health wants to reduce these complications by encouraging obstetricians (OBs) to reduce unnecessary C-section births among low-risk women.

Incentive: OBs can earn an additional $500 per quarter if they meet the C-section birth target set in their ACHA region for a total of up to $2,000 for the year.

Medicated Assisted Treatment (MAT) Incentive

Goal: Sunshine Health knows how critical it is to treat pregnant women with Opioid Use Disorder (OUD) through Medication-Assisted Treatment (MAT), the use of medication, counseling, and behavioral therapies to treat substance use disorders. Infants born to opioid users may suffer from Neonatal Abstinence Syndrome (NAS) and can experience preterm births, low birth weights, sepsis, feeding difficulties, tremors, seizures, and breathing problems. The American College of Obstetricians and Gynecologists (ACOG) recommends MAT because it is safe for pregnant women to take methadone or buprenorphine while breastfeeding. Sunshine Health also offers MAT training to providers to help them treat their patients.

Incentive: Trained Obstetrician-Gynecologists (OB/GYNs) and Behavioral Health (BH) providers can qualify for an additional $100 per claim filed per pregnant member for MAT services. Visit: Medication Assisted Treatment (MAT) Incentive

Training: Sunshine Health offers free, self-paced training sessions to help providers with the 8-hour training requirement for all Drug Enforcement Administration (DEA)-registered practitioners on the treatment and management of patients with opioid or other substance use disorders. Visit: Medication Assisted Treatment (MAT) Training

Notification of Pregnancy (NOP) Incentive

Goal: Sunshine Health knows this important document confirming that a member is pregnant is crucial to the future wellbeing of their new family. The Notification of Pregnancy (NOP) form brings the pregnant member, provider, and health plan together and allows Sunshine Health to start important services and benefits to ensure a healthy pregnancy and childbirth.

Incentive: Providers can receive $100 for each Notification of Pregnancy (NOP) form submitted within 30 days of a member’s first prenatal visit. Visit: Notice of Pregnancy (NOP) Incentive

Preterm Birth Incentives for Obstetricians (OBs)

Goal: Sunshine Health wants to safely reduce the number of preterm births because of the health risks facing babies born before 37 weeks. Organs such as the brain, lungs and liver are still developing up until birth, and prematurely born babies may face health complications at birth and later in life. In 2022, babies born too early (before 32 weeks) and at a low weight accounted for about 14% of infant deaths, according to the CDC. Obstetricians (OBs) can reduce preterm births by encouraging their patients to seek prenatal care early in their pregnancies, helping them to avoid alcohol, drugs and smoking during their pregnancies, and seeking medical attention if they experience early signs of preterm labor.

Incentive: OB providers can earn an additional $500 per quarter if they meet the preterm birth target set by the state in their AHCA region for a total of up to $2,000 a year.

  • Sunshine Health utilizes claims data to verify preterm births.
  • The incentive is applied at the Taxpayer Identification Number (TIN) level of the provider/group.
  • OB providers must have a minimum of 25 deliveries per quarter.
  • Note: Providers can qualify for all four quarters.
  • For more information and to view the AHCA regional targets, visit: Preterm Birth Incentives for Obstetricians (OBs)

PCP Birth Outcomes Incentive Program

Goal: Sunshine Health believes the best way to prevent undetected and untreated health risks from impacting a pregnancy is to discover them beforehand. We encourage Primary Care Providers (PCPs) to get their patients in for an examination early in their pregnancies to ensure that both the mother and fetus are healthy. Babies of mothers who do not get prenatal care are three times more likely to have low birth weights and five times more likely to die than those born to mothers who do receive prenatal care, according to the Office on Women’s Health.

Incentive: PCPs get $50 for each pregnant member they see in the first trimester.

  • The first prenatal care visit must occur during the patient’s first trimester, or before the 14th week of pregnancy.
  • Live birth deliveries from January 1 to October 7, 2026, are eligible for the incentive.
  • For more information visit: PCP Birth Outcomes Incentive Program

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Incentive

Goal: Sunshine Health believes it is crucial to help pregnant women with substance disorders. Substance use during pregnancy is a common and harmful condition that often ends up being ignored or managed poorly. It’s associated with poor outcomes such as preterm births, low birthweights, birth defects, developmental delays, and miscarriages. Sunshine Health encourages providers to engage their patients in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, an evidence-based approach that encourages behavioral changes.

Incentive: Providers who complete the Screening, Brief Intervention, and Referral to Treatment (SBIRT) assessment within each member’s first trimester are eligible for a $50 reimbursement per member.

Social Determinants of Health (SDOH) Incentive

Goal: Social, economic, and environmental conditions can have a significant impact on the health and quality of life of pregnant women. Sunshine Health wants to address the Social Determinants of Health (SDOH) of our pregnant members so we can improve their  outcomes and well-being before, during and after birth.

Incentive: Sunshine Health offers providers additional reimbursement to ensure our members receive assistance for their SDOH by submitting detailed claims or encounters using 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.

SDOH Incentives:

W-9 Tax Form

Providers must have an updated W-9 tax form on file with the health plan to ensure no disruptions in payment. To update your W-9, utilize the Provider Demographics Update tool.

Maternal Special Programs

Doula support: Sunshine Health covers doula services for pregnant members to improve prenatal and postpartum care and birth outcomes while reducing complications. Members receive unlimited doula visits, in-person labor support and 24/7 on-call support for 37 weeks until birth. Prior authorization is not required. Find a doula through Sunshine Health’s Find a Provider tool.

First Year of Life Program: This Sunshine Health program is dedicated to supporting mothers and their babes in their first 15 months together in areas such as health, nutrition, home safety, and regular visits to the child’s primary care provider (PCP). Visit: First Year of Life Program

Optum: Provides support, education and resources to improve neonatal health outcomes for preterm births and newborns admitted into the Neonatal Intensive Care Unit (NICU). Visit: Optum

Start Smart for Your Baby®: This program provides support and care for pregnant women before, during and after birth to help them with housing, food, clothing, cribs, and access to licensed medical staff if they experience any issues during their pregnancy. Visit: Start Smart for Your Baby®

Maternal Mental Health Programs

Brave Health: Virtual mental health services; members must be 13 years of age and up.

LunaJoy: Live, virtual, holistic mental health counseling for women through every phase of their lives with an emphasis on maternal mental health.

Teladoc Health: Virtual healthcare available to members of all ages.

Teladoc Health App: A mobile app that offers resources and support for addressing stress, depression, sleep issues, and other conditions tailored to each member’s individual needs.

Substance Abuse Special Programs

  • HALO: The Health Assistance, Linkage & Outreach program uses evidence-based care and a predictive model to treat members with an opioid use disorder.
  • Puff-Free Pregnancy: Pregnant members who complete four Tobacco Cessation Health Coaching Sessions within six months of the calendar year are eligible for a $5 reward for each completed session.

Maternal Health Resources

Baby Navigator: Dedicated to helping parents understand and monitor their baby’s social communication development and help them support their baby’s early learning and nurture the development of language and success in school.

Sunshine Health Connects: This Sunshine Health program links members and caregivers in need with local programs and support. Our database makes it easy for people with social needs, and those who help others, to find community programs. These programs provide help with food, shelter, healthcare, money and education, jobs and more. Sign up online to access these free tools and features.

HEAR HER® Campaign: This Centers for Disease Control and Prevention (CDC) program’s goal is to reduce pregnancy-related deaths by educating the public about pregnancy-related complications and to encourage a pregnant mother’s support system to listen to their health concerns and take them seriously. Visit: HEAR HER® Campaign

The Period of PURPLE Crying: The National Center on Shaken Baby Syndrome’s program to prevent shaken baby syndrome/abusive head trauma. Members can learn about early increased infant crying via videos, a PDF booklet and through the app.

Financial Resources

Members who need financial assistance or information can access these resources:

  • Hands on Banking: Financial education website sponsored by Wells Fargo. Explore topics like banking, buying a car, credit cards, loans, setting savings goals and more.
  • Money Smart: Financial education program that can help you create a positive relationship with money and banking. Hosted by the FDIC (Federal Deposit Insurance Corporation).
  • Practical Money Skills: Financial education for practical money skills. Browse learning games, financial calculators, and guides on how to handle money for different life events. From Visa.
  • Your Money Matters: Financial education website offering programs and information on wise money management. From the Florida Department of Financial Services Division of Consumer Services.
  • Take Control of Your Money: Browse guides on money topics, from getting out of debt and building credit to basic savings and how to deal with inflation. From Keys Federal Credit Union and Banzai.

Maternal Member Benefits and Programs

Standard Benefits

  • Obstetrician-Gynecologist (OB-GYN) visits (no limit).
  • Reproductive services for members who are pregnant or trying to become pregnant.
  • Confidential family planning services without prior approval for 18 years of age and under.
  • Primary care physician (PCP) visits for mother and child (no limit).

Medicaid Expanded Maternal/Child Benefits

These benefits are for members of these products:

Benefits:

  • 24/7 lactation support
  • Baby book
  • Biometric Equipment
  • Camp scholarship
  • Caregiver swimming lessons
  • Care grant
  • Cellular services
  • Childcare
  • Circumcision (newborns)
  • Dental kit
  • Doula services (unlimited)
  • Expanded prenatal services
    • Unlimited prenatal and postpartum provider visits
    • Access to breast pumps
  • Fatherhood engagement referral program
  • First Year of Life safe sleep
  • Fresh funds
  • Home delivered meals for pregnant members*
  • Mom care bundle
  • Non-emergency medical transportation
  • Nutritional counseling*
  • Over-The-Counter (OTC) baby supplies
  • Ready for baby bundles
  • Remote patient monitoring
  • Swimming lessons for children
  • Welcome Baby! Bundle
  • YMCA membership

* Prior authorization required.

MMA, CWSP, SMI, and HIV Member Healthy Rewards

Incentives are available to members of these health plans:

  • Sunshine Health Medicaid (MMA)
  •  Sunshine Health Pathway to Shine Specialty Plan (CWSP) Members
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI) Plan
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
Member Healthy Rewards

Amount

Activity

Description

$25

Notice of Pregnancy (NOP) Form (First Trimester)

Sign completed NOP form

$50

Prenatal Visit First Trimester

Complete first prenatal visit within first trimester or within 42 days of enrollment

$25 (up to $100)

Prenatal Visits

Complete up to four prenatal visits

$50

Doula Engagement

Complete six doula visits during pregnancy, including at least one postpartum visit

$20 per year

Puff-Free Pregnancy

 

Complete four tobacco cessation coaching sessions within six months of the calendar year

$40

Postpartum Visit

Complete postpartum follow-up visit 7-84 days after delivery

$25

Annual Well-Child Visit (WCV) Ages 0-21 Years

One visit per calendar year with Primary Care Provider (PCP).

·         Newborn well-child visit encouraged within 30 days of birth.

$20

Lead Screening, Children under Age 2 Years

Complete a blood test for lead poisoning screening by second birthday