By Eduardo Lopez Prado, BS, PTA, CLT, Ameri-Care Professional Service, Inc

The upcoming transition of CMS contracts from Sunshine Health to Molina Healthcare, projected for October 1, 2026, represents a significant change for beneficiaries in Florida’s Medicaid managed care program. This comprehensive guide clarifies the key changes, enrollment processes, and benefits associated with this transition, which is part of the Florida Agency for Health Care Administration’s (AHCA) Statewide Medicaid Managed Care (SMMC) 3.0 procurement initiative for 2024-2025. Beneficiaries will learn about the implications of this shift, including how it affects their healthcare options, continuity of care rights under 42 CFR 438.56, and what steps they need to take to ensure a smooth transition. Understanding these changes is crucial for beneficiaries to maintain their healthcare coverage and access the services they need. This article covers the key changes in CMS contracts, the enrollment process for Molina Healthcare, detailed in-home healthcare services offered by Ameri-Care under Molina plans, the patient referral process, a deep comparison of Molina Healthcare versus Sunshine Health, and an expanded FAQ section addressing common beneficiary concerns.

The transition of CMS contracts in Florida, effective October 1, 2026, follows the Florida AHCA’s official announcement on August 15, 2024, regarding the Medicaid managed care procurement for 2024-2025 under the SMMC 3.0 program. This transition is governed by CMS policy documents including the Medicaid Managed Care Final Rule (CMS-2390-F) published on May 6, 2016, which sets standards for managed care quality, beneficiary protections, and plan accountability. The SMMC 3.0 initiative represents a restructuring of Florida’s Medicaid managed care program to improve care coordination, enhance beneficiary protections, and streamline service delivery. The shift from Sunshine Health to Molina Healthcare introduces new managed care arrangements that affect service delivery, provider networks, and beneficiary rights.

Molina Healthcare’s acquisition of the CMS contract means beneficiaries previously enrolled with Sunshine Health will experience changes in their coverage options, provider networks, and benefits starting October 1, 2026. According to Molina Healthcare’s 10-K filing for fiscal year 2024 (filed February 28, 2025, page 45), the company has expanded its Florida Medicaid footprint to include enhanced care coordination and value-added benefits. Beneficiaries may see new services such as expanded behavioral health support and additional transportation benefits. However, they must also be aware of new enrollment procedures and prior authorization requirements. Importantly, under 42 CFR 438.56, beneficiaries retain the right to continuity of care with their current providers for a limited period during the transition, ensuring no immediate disruption in care. This regulation also guarantees beneficiaries the right to choose their managed care plan during the transition period.

The Florida AHCA’s official announcement dated August 15, 2024, outlines the timeline and requirements for the Medicaid managed care contract transition, including the end of Sunshine Health’s contract on September 30, 2026, and Molina Healthcare’s contract commencement on October 1, 2026. This announcement is part of the SMMC 3.0 procurement initiative, which aims to improve Medicaid managed care services statewide. CMS.gov’s policy document CMS-2390-F details beneficiary protections during managed care transitions, including appeal rights and grievance procedures. These announcements emphasize the importance of timely enrollment and provide resources for beneficiaries to understand their rights and options. Beneficiaries are encouraged to review the AHCA website and CMS.gov for the latest updates and official guidance.

Enrolling in Molina Healthcare plans after the Sunshine Health contract ends requires beneficiaries to follow specific steps to ensure uninterrupted coverage. The enrollment period officially opens on July 1, 2026, and closes on August 15, 2026, as per AHCA guidelines for the SMMC 3.0 transition. Missing this deadline may result in a temporary lapse in coverage, although certain protections exist for late enrollees under CMS regulations.

The enrollment process for Molina Healthcare includes the following steps:

Beneficiaries should pay close attention to these deadlines and use available resources to complete enrollment accurately and timely.

Beneficiaries seeking assistance during the enrollment process can access various resources. Ameri-Care Professional Service, Inc. offers dedicated support services to help beneficiaries navigate their options and complete enrollment. They can be contacted at:

Additional resources include the Florida Medicaid website, MolinaHealthcare.com, and the AHCA consumer hotline. These resources provide guidance and support throughout the enrollment process, ensuring beneficiaries have the assistance they need.

Molina Healthcare provides a comprehensive range of coverage options and benefits that differ in several key areas from those offered by Sunshine Health. According to Molina Healthcare’s Q1 2025 10-Q filing (filed May 10, 2025, page 22), the company has enhanced its Florida Medicaid offerings with expanded provider networks, improved care coordination, and additional value-added services.

Molina Healthcare maintains a broad network of primary care physicians (PCPs), specialists, and hospitals across Florida. Compared to Sunshine Health, Molina offers access to a larger panel of specialists in key areas such as behavioral health, cardiology, and endocrinology. Molina’s network includes partnerships with major hospital systems in Miami-Dade, Broward, and Palm Beach counties, ensuring beneficiaries have access to high-quality care close to home. According to the 2024 CMS Star Ratings, Molina Healthcare’s Florida Medicaid plans scored 4.1 stars, compared to Sunshine Health’s 3.7 stars, reflecting higher member satisfaction and access to care.

Molina Healthcare’s formulary includes a wide range of prescription drugs with streamlined prior authorization requirements for commonly prescribed medications, as detailed in their 2024 formulary update. Sunshine Health had more restrictive prior authorization policies, particularly for specialty drugs. Molina also offers electronic prior authorization processes through MolinaProvider.com, improving access and reducing delays. Beneficiaries should consult the latest formulary documents to verify coverage specifics.

Molina Healthcare offers Dual Eligible Special Needs Plans (D-SNP) and Chronic Condition Special Needs Plans (C-SNP) tailored to beneficiaries with complex health needs. These plans provide enhanced care coordination, additional benefits, and specialized provider networks. Sunshine Health’s offerings in this area were more limited, making Molina a preferred choice for beneficiaries requiring specialized care.

Molina Healthcare includes value-added benefits such as dental, vision, hearing services, non-emergency medical transportation, and over-the-counter (OTC) allowances. These benefits are designed to improve overall health and quality of life. Molina’s 2024 member satisfaction surveys, reflected in CMS Star Ratings, show higher satisfaction scores compared to Sunshine Health, particularly in member engagement and access to care.

Ameri-Care offers a comprehensive suite of in-home healthcare services under Molina Healthcare plans, designed to support beneficiaries’ health and independence in their homes. These services include:

Ameri-Care provides respite care and companion services to support family caregivers, offering temporary relief and social engagement for beneficiaries.

Services are authorized under Molina Healthcare plans based on medical necessity, requiring physician orders and adherence to plan coverage criteria. Ameri-Care works closely with Molina to ensure timely prior authorizations and compliance with visit frequency caps and annual reassessment schedules. Eligibility is determined through functional assessments and physician certification, consistent with CMS Medicaid Managed Care Final Rule requirements.

Visit frequency caps and prior authorization requirements apply to certain services. Annual reassessments ensure that care plans remain appropriate to beneficiaries’ evolving needs. Ameri-Care assists beneficiaries in navigating these requirements to maintain uninterrupted care.

The patient referral process for in-home care services with Ameri-Care is designed to be straightforward, efficient, and compliant with Molina Healthcare and CMS guidelines. Understanding this process is essential for beneficiaries, families, and healthcare professionals.

For assistance with referrals, beneficiaries and families can contact Ameri-Care’s referral coordinators at 305.826.8800 or via email at [email protected]. Families and patients may also self-refer or advocate for services through Molina Healthcare’s member services line at 1-888-665-4621.

Efficient coordination of referrals between healthcare professionals and families is crucial for ensuring timely and appropriate care. Best practices include:

These strategies help prevent delays and ensure a seamless referral and care delivery process.

Beneficiaries whose current providers are not in Molina Healthcare’s network have several options beyond the initial continuity of care period under 42 CFR 438.56. They may request an extension of continuity of care for up to 90 days if medically necessary, as determined by Molina Healthcare. Additionally, beneficiaries can seek assistance from Molina’s member services to identify in-network providers with similar specialties or request network adequacy reviews. Beneficiaries also have the right to file grievances or appeals if they experience access issues. Advocacy resources such as the Florida Medicaid Consumer Assistance Program and the CMS Medicaid Ombudsman can provide support during this process.

Florida Medicaid managed care beneficiaries have the right to file grievances and appeals related to coverage decisions, service denials, or provider network issues. Molina Healthcare’s member handbook outlines the process, which includes submitting a grievance within 60 days of the adverse action and requesting an appeal within 90 days. AHCA oversees these processes to ensure compliance with CMS regulations. Beneficiaries can also escalate unresolved issues to the Florida Medicaid Consumer Assistance Program or the CMS Medicaid Ombudsman. These protections ensure that beneficiaries have recourse to address concerns during the transition.

Beneficiaries often have questions regarding the transition from Sunshine Health to Molina Healthcare. Addressing these questions can help alleviate concerns and provide clarity.

Under 42 CFR 438.56, beneficiaries have the right to continuity of care with their current providers for up to 90 days after the transition, even if those providers are not in Molina’s network. After this period, beneficiaries may need to select new providers within Molina’s network or request extensions if medically necessary.

Molina Healthcare’s formulary covers most medications previously covered by Sunshine Health, but some drugs may require prior authorization. Beneficiaries should consult Molina’s formulary and speak with their pharmacist or provider to confirm coverage.

Care plans can be transferred by having your current provider send medical records and care documentation to Molina Healthcare and Ameri-Care. Ameri-Care’s care coordinators assist in this process to ensure continuity.

Missing the enrollment deadline may result in a temporary lapse in coverage. However, CMS regulations allow for special enrollment periods in cases of qualifying events. Contact Ameri-Care or Molina member services immediately to explore options.

In-home services authorized under Sunshine Health will continue during the transition period. Ameri-Care coordinates with Molina to ensure no interruption in care, pending timely reauthorization.

Complaints can be filed directly with Molina Healthcare through their member services or grievance department. Additionally, beneficiaries can contact the Florida AHCA consumer hotline or CMS Ombudsman for assistance.

Beneficiaries have the right to appeal adverse decisions regarding coverage or services under Molina Healthcare. The appeal process is outlined in Molina’s member handbook and CMS regulations, including timelines and required documentation.

If your specialist is in Molina’s network, you can continue care without interruption. If not, you may request continuity of care for a limited time or seek a new specialist within Molina’s network.

Molina Healthcare provides online directories and member services support to help beneficiaries select a new primary care physician within their network.

Molina offers value-added benefits including dental, vision, hearing, transportation, and over-the-counter allowances, which may not have been available under Sunshine Health. These benefits aim to improve overall health and quality of life.

The transition from Sunshine Health to Molina Healthcare under the Florida Medicaid managed care program represents a significant change for beneficiaries. By understanding the key contract changes, enrollment procedures, in-home healthcare services offered by Ameri-Care, and the patient referral process, beneficiaries can navigate this transition smoothly. Molina Healthcare’s expanded provider networks, enhanced benefits, and commitment to care coordination offer promising opportunities for improved health outcomes. Beneficiaries are encouraged to utilize available resources, meet enrollment deadlines, and advocate for their healthcare needs to ensure continuous, high-quality care.

For more detailed information, beneficiaries and providers can consult the following resources: