Sunshine Health is Florida’s Leading Medicaid Managed Care Provider


Sunshine Health is Florida’s premier Medicaid-managed care provider. Our team is committed to helping members take control of their care by improving community health one person at a time.

AHCA’s exemplary and corrective action plan placed five requirements on Sunshine, including that its claims processing systems function for at least one month. Furthermore, training must also be offered to providers.

Quality Assurance Program Improvement (QAPI)

Adequate quality assurance and performance improvement (QAPI) programs are integral to long-term care regulatory compliance, so AHCA/NCAL offers many free tools, resources, webinars, and guides to assist members with creating comprehensive QAPI programs to comply with CMS requirements. Furthermore, its “QAPI at a Glance Guide” gives facilities a snapshot of 12 actions they can take immediately to complete their program.

QAPI combines two complementary approaches to quality: Quality Assurance and Performance Improvement. While Quality Assurance involves reactive inspections to verify clinical outcomes, Performance Improvement takes an active approach towards optimizing clinical and non-clinical processes and procedures with its front-line staff participating in shaping this improvement process and applying their knowledge and expertise for bettering resident outcomes and quality of life.

A Quality Assessment, Planning, and Improvement (QAPI) program should encompass all systems of care and management practices at a facility, emphasizing safety, high-quality resident care, resident choice, and overall quality of life. A QAPI program must also align with organizational goals, mission, and vision while being supported with sufficient resources for implementation and administration.

Nursing home leaders must fully participate in the Quality Assurance Performance Initiative process and offer support to their teams. This means identifying individuals to lead and coordinate it – ideally, someone familiar with regulations and experience creating quality assurance programs. Furthermore, leaders must give their staff members enough time, funding, and technical assistance to implement a QAPI program successfully.

Nursing homes may find the Quality Assessment, Performance Improvement (QAPI) process challenging as it involves interpreting large volumes of data to formulate actionable steps that improve resident outcomes. McBee can assist your organization with this challenge through its Quality Assurance Performance Improvement services, helping develop, implement, and maintain an effective program to meet compliance standards required by the Centers for Medicare & Medicaid Services (CMS) Requirements of Participation or Value-Based Purchasing (VBP). Learn more here about these services!

Preventive & Clinical Practice Guidelines

Sunshine Health is a managed care company in Florida offering various healthcare services. Their health insurance plans cater to children, adults, and seniors, while their behavioral health services assist those suffering from severe mental illnesses. Furthermore, financial assistance helps families cover premium costs more easily; wellness services and health education programs are provided, while fully-funded scholarships for students interested in healthcare careers.

Sunshine Health and Johns Hopkins All Children’s Hospital have formed a new partnership to expand access for Florida Medicaid beneficiaries to primary care services through value-based agreements that incentivize enhanced outcomes through further provider reimbursement, making this two-year agreement an essential step towards improving healthcare access for Florida Medicaid beneficiaries.

Sunshine Health has adopted evidence-based guidelines to increase the quality of clinical preventive services. These guidelines aim to give healthcare providers access to the latest available information on which preventive services patients should receive and are created through a rigorous process that incorporates input from patient organizations, clinicians, and experts in prevention. In addition, IDSA has created a Handbook for Clinical Practice Guidelines Development as a means of helping guideline developers meet these standards.

The National Academy of Medicine and U.S. Preventive Services Task Force are committed to making their recommendation development process as clear and transparent as possible. Hence, all stakeholders remain informed at every stage. The following table details each step to develop recommendations in line with the NAM model for Clinical Practice Guidelines We Can Trust (see table below).

Ambetter from Sunshine Health is the brand name of Florida residents’ health insurance Marketplace plans sold by Sunshine Health, Inc. This plan offers three metal plans in the Health Insurance Marketplace – Essential Care Bronze, Balanced Care Silver, and Secure Care Gold – making shopping online for healthcare plans easy for Florida residents. Residents can select a plan to meet their individual needs and budget with help available through federal exchange plans; eligible applicants may even get assistance paying their monthly premium.

Community Connections Grants

The Community Connections Grants program funds projects that assist residents of color in tapping into broadband service’s potential for economic development, education, healthcare, and public safety. Eligible applicants include non-profit community-based organizations and advocates, government agencies (including tribal governments ), schools, and for-profit entities. Submissions are reviewed competitively, with those showing particular promise invited to submit a full proposal.

Projects must demonstrate an innovative and creative approach to improving quality of life, building community relationships, and providing opportunities to advance local economies. Funding must not be used to replace existing programming or operations. At the same time, applicants must demonstrate that the proposed project or program will remain sustainable after its initial grant period ends.

Improving health and building healthy, connected communities require solutions that combine system enhancements with those proposed by local leaders and residents. Change must focus on strengthening people and places rather than solely meeting needs. In 2014, The Greater Milwaukee Foundation, Zilber Family Foundation, and Northwestern Mutual Foundation jointly launched the Community Connections small grants program supporting neighborhood leaders pursuing projects that bring people closer together within their localities.

Since then, nearly 30 projects in Greater Milwaukee have been funded, from positive body image workshops for teenage girls in Sherman Park to community book clubs in Lindsay Heights and an initiative to install more security cameras in the alleyways of Grasslyn Manor.

These initiatives are part of Smart Growth America’s efforts to revitalize neighborhoods nationwide and remove obstructions to people relocating where and when they want. Community Connectors who work on restoring their local areas are supported with tools and resources from Smart Growth America that help this work.

The Community Connectors toolkit features webinars, guides, and resources for community leaders looking to bring people together in their local areas to build better, healthier spaces. It also features a map with profiles of these community connectors working hard to get everyone closer together for positive change.

Value-Based Payments

Value-based payments hold healthcare providers accountable for cost and quality of care. They replace outdated fee-for-service reimbursement models with models that link provider compensation with performance metrics defined by government agencies or individual health systems such as CMS or their metric development teams. As measures score higher, they yield greater financial rewards to providers – including patient outcomes such as post-hospitalization readmission rates and total per capita costs and utilization measures.

As opposed to traditional fee-for-service models, these models may reduce costs while simultaneously improving patients’ health and financial outcomes. However, they face several hurdles that must be addressed to succeed – such as prioritizing equity issues across payers, aligning incentives across payers, and streamlining operations to enable adoption.

While these challenges may appear daunting, they are essential to the long-term success of value-based payment models. All parties involved must be fully engaged and invested in making them work; to do this effectively, the industry must invest in the infrastructure needed to implement value-based payment programs successfully. This may involve improving data availability and uniformity, creating interoperability among programs, leveraging existing technology solutions for ease of model implementation processes, etc.

At present, value-based payments appear to be gathering steam. According to the Health Care Payment Learning and Action Network (LAN), such models now account for 34% of U.S. healthcare spending. Although their level of accountability varies, all share one common objective: rewarding providers who deliver high-value care while controlling costs.

However, not all physicians support the transition to value-based payment models. A 2018 Quest Diagnostics survey discovered widespread reluctance by physicians to participate in value-based payment models due to difficulty meeting quality and productivity requirements. Yet despite these challenges, it’s essential to remember there are financial and business advantages to shifting away from the traditional fee-for-service model.