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1 Sunshine Health Managed Medical Assistance (MMA) Program
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Sunshine Health
Managed Medical Assistance
(MMA) Program
Three Key Products
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• Sunshine Health Managed Medical Assistance (MMA)
• Sunshine Health Child Welfare
• Sunshine Health Tango Plan – Long-Term Care (LTC)
Regions by Counties/MMA
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3 Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton,
Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
Suwannee, and Union
4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia,
5 Pasco, and Pinellas
6 Hardee, Highlands, Hillsborough, Manatee, and Polk
7 Brevard, Orange, Osceola, and Seminole
8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
9 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
10 Broward
11 Miami-Dade and Monroe
Enrollment Process
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• AHCA or its agents notifies Sunshine Health of an enrollee’s selection
or assignment to the Plan. AHCA or its enrollment broker sends written
confirmation to enrollees of the chosen or assigned Managed Care
Plan. Notice to the enrollee is sent by mail. Notice to Sunshine Health
will be by file transfer.
• Sunshine Health will assign PCP to the enrollees who have not
chosen a PCP. AHCA’s confirmation notice will advise the enrollee of
this process.
• Enrollment in Sunshine Health, whether chosen or assigned, will be
effective at 12:01 a.m. on the first calendar day of the month following
a selection or assignment that occurs between the first calendar day of
the month and the last Saturday of the month.
New Member Information
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• Upon enrollment in Sunshine Health, members receive a Member
Handbook and a Sunshine Health Member ID card.
• NurseWise attempts to contact new members to complete a Health
Risk Screening (HRS) to identify members with continuity of care
needs or those who may benefit from case management.
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Clinical Management
Top 10 Diagnoses
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• 5.2 % Respiratory including:
• Bronchitis, COPD, Asthma, pneumonia, reactive airway
• 3.0 % Diabetes
• 2.8% Hypertension
• 2.5% Coronary Artery Disease including:
• Chest pain, MI, coronary artery blockage, HF
• Others: fractures, abdominal pain, infection/sepsis,
gastroenteritis/colitis, kidney failure, behavioral health
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Utilization Management Tools
Some of the Utilization Management Tools:
• Policies and Procedures
• InterQual
• Concurrent review for inpatient admissions
• Daily reports such as census, turn around time, admits/day 1000
• Medical Management System- TruCare
• Fax system- Right fax and FileNet (CDMS)
• Claims system- Amisys
• Customer Relationship Management (CRM)
• Provider Data Management (PDM)
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Case Management
Centene and Sunshine Health adhere to the Case Management Society of
America’s (CMSA) definition of case management.
“A collaborative process of assessment, planning, facilitation and advocacy
for options and services to meet an individual’s health needs through
communication and available resources to promote quality cost-effective
outcomes.”
Case management is appropriate for members needing a higher level of
service with clinical needs. Members in case management may have a
complex condition, multiple co-morbidities or those that are frail, elderly,
disabled, or at the end of life. Members in case management typically can
benefit from education on how to manage their health condition(s),
assistance in accessing health care services, linking to community
resources, and additional family or other care giver
support/education. These members mostly need moderate to minimal
assistance from a case manager for a short period of time.
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Health Management Programs
Health management programs are managed by our partner Nurtur.
Interventions and educational programs designed for individuals with
chronic conditions designed to prevent recurrence of symptoms, maintain
high quality of life, and prevent future need for medical resources by
using an integrated, comprehensive approach to healthcare.
Nurtur provides the following programs:
• Diabetes Mellitus (DM)
• Heart Failure
• Chronic Obstructive Pulmonary Disease (COPD)
• Asthma
• Hypertension (HTN)
• Developmental Delay and Autism
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Health and Wellness
Designed to address the health status of our members across the
continuum of health from wellness to the management of one or more
chronic conditions. It is rooted in the philosophy of “meeting the
member where they are,” supporting them to take that first step, and to
continue the healthy behaviors necessary to improve their health.
• Health and Wellness
• Condition Management
• Lifestyle Risk Behaviors
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Behavioral Health
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Appointment Standards
Type of Care Standard
Emergency Care with Crisis
Stabilization
Within twenty-four (24) hours.
Urgent Care Within forty-eight (48) hours.
Post Discharge from Hospital Within seven (7) days.
Routine Referrals Fourteen (14) calendar days.
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Provider Resources
• Provider Manual
• Quick Reference Guide
• Frequently Asked Questions
• Provider Directory
• Cultural Competency Plan
• Outpatient Treatment Request (OTR) Form
• PCP Communication Form
• Address Change/Update Form
• E-Learning
• User Manual – Provider Portal
• Educational Brochures
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Covered Services
• Inpatient Mental Health.
• Observation.
• Electroconvulsive Therapy (ECT).
• Outpatient Mental Health services provided by a psychiatrist
including medication management.
• Community Mental Health Center Services.
• Crisis Services.
• Adult and Child Targeted Case Management.
• Federally Qualified Health Center (FQHC), Rural Health Center
(RHC), and Primary Care Clinic (PCC) Behavioral Health Services.
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Covered Services (continued)
• Substance use services for children, pregnant women, and in
cases where acute care physical health services related to
substance use or detoxification are necessary.
• Residential Treatment for Mental Health and Substance Abuse.
• Statewide Inpatient Psychiatric Programs (SIPP) Art Therapy.
• Telemedicine.
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Standards of Care
• Sunshine Health focuses on collaborating with providers to ensure
the best care and outcomes possible, and coordination with our
ICM/CC staff is imperative.
• As an NCQA accredited organization, Sunshine Health adheres to
HEDIS seven day follow up measures when a member has been
discharged from an inpatient setting.
• Our expectation is that a member will have a follow up appointment
scheduled with a licensed behavioral health professional within
seven days at the time of discharge. Sunshine Health case
management staff are able to assist as needed with scheduling this
appointment.
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Standards of Care (continued)
• Additionally, Sunshine Health case management staff will follow up
with members after discharge to assist with alleviating any barriers
to treatment adherence with this appointment.
• Case management Staff also provide members with discharge tool
kits to provide resources related to mental illness, medication
adherence, developing a wellness plan etc.
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Case Management
We recognize that multiple co-morbidities will be common among our
membership. The goal of our program is to collaborate with the member
and all treating providers to achieve the highest possible levels of
wellness, functioning and quality of life.
Sunshine Health’s case management model uses an integrated team of:
• Licensed mental health professionals
• Registered nurses
• Social workers
• Non-clinical staff
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Case Management (continued)
Sunshine Health’s case management model is designed to:
• Educate members on the importance of treatment compliance.
• Help members obtain needed services.
• Assist in coordination of covered services, community services,
or other non-covered venues.
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Why We Integrate Care
People with mental and/or substance abuse disorders may die decades
earlier than the average person.
Mostly from untreated and preventable chronic illnesses like:
• hypertension
• diabetes
• obesity
• cardiovascular disease
These illnesses are aggravated by poor health habits like:
• inadequate physical activity
• poor nutrition
• smoking
• substance abuse
Barriers to primary care coupled with challenges in navigating complex
healthcare systems have been a major obstacle to care.
http://www.integration.samhsa.gov/about-us/what-is-integrated-care
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Clinical Behavioral Health Models
• Integrated Care
• Clinical Training and Development
• Disease Management
• Child Welfare
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Integration of Physical and Behavior Health
• Within thirty days the case manager completes an assessment to help
determine the behavioral health and physical health needs. When a member
has both behavioral health and physical health conditions, the case manager
follows the process identified in the four quadrant integration model to assign
a primary case manager.
• The model serves as the conceptual framework for collaborative planning.
Each quadrant considers the behavioral health and physical health risks and
complexity of the population and appropriate ways to meet the member’s
needs.
• ICM/CC will provide coordination of services for members. – ICM/CC will assure member has a 7 day f/u appt post DC.
– ICM/CC will provide calls to OP providers to confirm appointments are in place.
– ICM/CC will follow up with OP providers to confirm appointments have been
attended.
– (if hospital has failed to schedule and/or coordinate efforts with ICM/CC, ICM/CC to
schedule a 7 day f/u appt utilizing list of contracted providers
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Different Levels of Intervention • Based on an assessment of the member’s physical and behavioral
health conditions, social considerations, and other barriers, the level of
intervention to support the member is determined. This can be:
• High – follow-up at least weekly
• Moderate – follow-up at least monthly
• Low – follow-up at least quarterly
• From this determination, case management or care coordination
occurs.
• Key Interventions
– Coordinate care with the member’s PCP and behavioral health provider
– Facilitate communication across member’s all treating providers and continuum of
care
– Facilitate appointments for all needed care
– Educate member and caregivers about their diagnoses, self-management
principles, identification of symptoms, and medications.
– Educate member on their benefits and how to access them
– Identify and facilitate linkage to appropriate community supports
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Summary
Sunshine Health uses a complex coordinated approach that involves
input from:
• AHCA
• Providers
• Clinical Staff
• Pharmacy Staff
• Training Team
• Quality Staff
• Members
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Contact Information:
Medical Management Debra Smyers, SVP, Med Management, Medical Affairs
(866) 796-0530
Behavioral Health Rebekah Paone, Clinical Director
(866) 796-0530
Tonia James, Clinical Manager
(866) 796-0530
