Florida failed for nearly 3 months to pay tens of thousands of health claims for children (2022)

Published Feb. 14

GAINESVILLE – Florida failed for nearly three months to pay tens of thousands of health care claims for the state’s sickest and neediest children due to software glitches blamed on the corporate merger of its two largest payment vendors, officials and executives said.

Families with critically ill children who relied on Medicaid-paid health providers were stranded in some cases. A father in Lake Worth was forced to cut back his contractor work to remain home and care for his son when payments stopped. A mother in Ocala said the company that helped care for her 15-year-old disabled son temporarily shut down because of the payment problems.

“We had to find caregivers for him,” said AnnMarie Sossong of Ocala, whose son has a neuro-immune condition and profound autism. “You can’t do anything else. You can’t go to work, you can’t go to school, you can’t even make a phone call because you’ve got this kid with such high needs,” she said.

Payment problems panicked more families, especially as unpaid bills for nursing care and other home health services began stacking up over months with no quick resolution in sight.

Executives at Sunshine State Health Plan Inc. of Tampa, Florida’s largest Medicaid payment vendor, said the payment glitches stemmed from the company’s merger on Oct. 1 with the second-largest payment vendor, WellCare of Florida Inc. Combined, Sunshine and Wellcare have multi-year contracts worth $31.6 billion from the state’s Agency for Health Care Administration, according to figures from the state’s chief financial officer.

Related: Wellcare and Centene close on $17 billion merger

It was among the most serious technology meltdowns — affecting one of the most vulnerable populations — under the administration of Gov. Ron DeSantis since unemployment claims overwhelmed Florida’s Department of Economic Opportunity early in the pandemic.

“Nobody responded to all these cries for help,” said Lavette Gulley, owner of Serenity Companion Service Inc., which cared for Sossong’s son. She temporarily closed her company due to unpaid invoices, stranding families that relied on the services she provided. “Some of these kids I’ve been with six, seven years, and I never had to call those parents and say, ‘Hey, I’ve got to stop service because I’m not getting paid.’”

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Dan Miller of Lake Worth is a single father of a 17-year-old son with autism and an electrical contractor. His son’s provider, Blessing Hands Services Inc. of nearby Palm Springs, stopped the family’s services after it went unpaid for months, forcing him to take time from work to care for his son full time. He said he was at risk financially of losing his family’s home.

“I have jobs right now that I’m in fear of losing because I can’t get to them and can’t get them finished fast enough,” he said. “It’s very bad for me right now financially.”

Sunshine said it realized the scale of the growing issues paying health care providers by December, and by January was discussing its problems with the Agency for Health Care Administration. The agency confirmed it wasn’t aware of problems until January — and indicated it found out about the problems from others, not Sunshine.

Florida failed for nearly 3 months to pay tens of thousands of health claims for children (1)

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Sunshine said the problems affected children receiving care under its Sunshine Health Medicaid program and the Children’s Medical Services Health Plan it operates on behalf of the Florida Department of Health, for patients under 21 who are eligible for Medicaid and who have serious, chronic conditions.

Gulley, the owner of the health provider Serenity, said payment problems started far earlier than December. She said she was unable to submit claims in late October. In November, she noticed some children who were clients were missing from Sunshine’s system. She said she remained on hold with the company by phone one day for eight hours before the call was disconnected. Parents told her they also were filing grievances with Sunshine over unpaid bills for services for their children.

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“At the end of December, I knew I was going to have to shut my doors after 26 years,” Gulley said. She was able to restart her business over the last two weeks.

Frustrated families said they did not blame their children’s health providers who weren’t being paid.

“I don’t know how she’s staying in business,” said Miller, the father in Lake Worth who owns Miller Electric Inc. “I couldn’t go three months without getting any money coming in and still pay payroll if I had somebody working for me.”

The Agency for Health Care Administration said in a statement it was considering “all available recourse options” to punish Sunshine Health — including “liquidated damages and sanctions” — if its investigation determines the company had violated terms of its contract.

The improperly rejected payments were all re-processed by Jan. 31, Sunshine said. Even though the problems involved its work under a government contract, it declined in interviews over six days to specify the number of families it estimated were affected, the number of health care providers whose payments were rejected, the exact number of claims it improperly rejected — or even identify who at the Agency for Health Care Administration it was notifying.

The company said in a statement that “relatively few” providers were affected, representing what it said
were one-half of 1 percent of its 9.2 million total payment claims it processed during the period. That works out to be 46,000 rejected claims, although the figure is believed to be closer to 30,000 rejected claims from roughly 400 health care providers.

The company was communicating with the state agency’s No. 2 in command, Chief of Staff Cody L. Farrill, who coordinates Medicaid issues with other Florida agencies, the U.S. government and the Legislature. Farrill’s office has not yet responded to a Feb. 3 request under Florida’s public records law for copies of emails or other communications he exchanged with Sunshine about the crisis.

Owners of another health provider, The Lamp Post Therapy Center LLC of Gainesville, also said they weren’t paid after the Sunshine corporate merger. It provides occupational and speech therapy services. “It’s been since maybe October when they took over, so that’s a lot of time to go without a paycheck,” CEO Elise Caton said.

The payment problems have drawn almost no public attention. Sunshine acknowledged payment issues in a press release it published on its website Jan. 20, blaming it on an unspecified information technology problem and not hinting at the scale or seriousness of the issue.

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A former Politico health journalist, Alexandra Glorioso of Tallahassee, wrote Jan. 28 in a blog that she had contacted seven health providers offering services across 10 counties that complained that Sunshine wasn’t paying them. One provider told her problems were widespread and affecting companies across Florida, but she wrote that the company and government officials wouldn’t provide details.

Glorioso said she asked the chairperson of the Senate Appropriations Subcommittee on Health and Human Services, Sen. Aaron Bean, R-Fernandina Beach, about the problems, and he told her they were not widespread. Bean’s subcommittee helps oversee the Medicaid program in Florida, and he is president pro tempore in the Senate. Bean did not return messages over three days left on his cell phone or emails sent to him and his legislative staff.

Glorioso said a mutual friend of one health provider, speech pathologist Andrea Clark of Hudson near Tampa, complained Jan. 19 to House Speaker Chris Sprowls, R-Clearwater, and within a day Farrill and the state agency’s assistant deputy secretary, Brian Meyer, told Clark they were investigating.

In its statement responding to questions for this news article, the Agency for Health Care Administration said as soon as it was made aware of the problems, in January, it immediately contacted Sunshine for details and answers about how it was fixing the issues.

In its own statement, Sunshine said, “We regularly update our regulators on all aspects of our operations.” It said it had notified the state agency in December about what it described as “isolated, integration-related claims issues.”

Executives and officials said no one inside the combined health care giant so far has lost their jobs over the payment failures after the merger, for which the companies spent months planning and preparing. “While we do not discuss employee relations matters publicly, Sunshine Health has aggressively worked to fix these provider claims issues,” the company said in a statement.

Sossong, the mother in Ocala, said she sacrificed time trying to find alternate care for her son when her provider shut down. The situation left her unsure whether she could work shifts or attend her nursing classes.

“You’re hurting these very vulnerable families,” she said. “There was a lot of extra stress put on our lives because we weren’t able to find care for my son.”

This story was produced by Fresh Take Florida, a news service of the University of Florida College of Journalism and Communications. The reporter can be reached at kristin.bausch@freshtakeflorida.com.

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FAQs

Did Staywell change to Sunshine Health? ›

In most cases, your care manager and your providers will stay the same. Plus, our provider network is growing to give you even more choices. On Oct. 1, 2021, our Staywell name will go away and you will become a Sunshine Health Long Term Care member.

Is wellcare changing to sunshine? ›

On October 1, 2021, the Staywell name will go away and your Staywell Medicaid patients will become Sunshine Health members.

Is Sunshine Health a Medicaid? ›

Sunshine Health

We provide quality healthcare coverage with expanded benefits to individuals and families to help them get well and stay well through through our Medicaid, Long Term Care and specialty plans.

Is Sunshine Health the same as Florida Medicaid? ›

Sunshine Health is a Florida Medicaid health plan and a wholly-owned subsidiary of Centene Corporation, a leading multi-line healthcare enterprise offering both core Medicaid and specialty services.

Is Staywell Florida Medicaid? ›

Staywell Health Plan is a Managed Care Plan with a Florida Medicaid contract. The benefit information provided is a brief summary, not a complete description of benefits.

Is Wellcare a Chinese company? ›

Everyone at Wellcare has your best interest at heart to provide the best products to show we sincerely care. Headquartered in Taiwan, the two sisters established R&D, Marketing, QA departments in Taiwan and manufacturing facility in China, with markets all over Europe, America, and Asia.

What's the difference between Humana and Wellcare? ›

Wellcare offers Medicare Part D prescription drug plans and Medicare Advantage plans in certain parts of the country. Humana, on the other hand, sells Part D plans, Medicare Advantage plans and Medicare Supplement Insurance (Medigap) plans.

Are Obamacare and Medicaid the same? ›

The most important difference between Medicaid and Obamacare is that Obamacare health plans are offered by private health insurance companies while Medicaid is a government program (albeit often administered by private insurance companies that offer Medicaid managed care services).

How many types of Medicaid are there in Florida? ›

In Florida, most Medicaid recipients are enrolled in the Statewide Medicaid Managed Care program. The program has three parts: Managed Medical Assistance, Long-Term Care, and Dental.

What Medicaid covers Florida? ›

Medicaid services may include: physician, hospital, family planning (birth control, pregnancy and birth care), home health care, nursing home, hospice, transportation, dental and visual, community behavioral health, services through the Child Health Check-Up program, and other types of services.

Why is Florida Medicaid so hard to get? ›

Income limits to qualify for Medicaid in Florida are very low, and most adults who don't have children aren't eligible to enroll.

What is the best Medicare in Florida? ›

Top-Rated Medicare Advantage Plans in Florida
  • HealthSun Health Plans, Inc. HealthSun HealthAdvantage Plan (HMO) HealthSun HealthAdvantage Plus (HMO) ...
  • Optimum HealthCare, Inc. Optimum Gold Plan (HMO) Optimum Gold Plus Plan (HMO) ...
  • UnitedHealthcare. Erickson Advantage Freedom (HMO-POS)

Is Medicaid the same as Florida Healthy Kids? ›

Florida KidCare is the umbrella brand for the four government-sponsored health insurance programs – Medicaid, MediKids, Florida Healthy Kids and the Children's Medical Services (CMS) Health Plan – that together provide a seamless continuum of coverage for Florida children from birth through the end of age 18.

How much money can I have in the bank on Medicaid in Florida? ›

How Much Can a Person Own and Qualify for Medicaid in Florida? A person who otherwise qualifies for Medicaid can have no more than $2000 in countable assets. I often suggest keeping that number much lower than $2000 (the last thing you want is an accumulation of Personal Needs Allowance funds to cause ineligibility).

How long can a child stay on Medicaid in Florida? ›

Once the last child in the household turns 18 years of age, the parent(s) or other caretaker relative loses eligibility for coverage in Family-Related Medicaid.

How much money can you have in the bank to qualify for Medicaid in FL? ›

Florida allows an individual to retain less than $2,000 in non-exempt assets, in addition to certain exempt assets. If the individual is married, than the Agency allows the well-spouse to retain a "Community Spouse Resource Allowance" (Community Spouse Resource Allowance" (CSRA) of up to $119, 220.00.

What did WellCare used to be called? ›

WellCare Health Plans, Inc.

Is UnitedHealthcare owned by China? ›

With a dedication to offering comprehensive premium healthcare services in China, UFH was later acquired by China-focused investment firm New Frontier Corporation in 2019.

What is another name for WellCare? ›

Wellcare was founded in 1985 and became a subsidiary of Centene in 2020. The company's headquarters are in Tampa, Florida. Wellcare offers coverage through Medicaid, Medicare Advantage and Medicare prescription drug plans. As of October 2022, Centene covered nearly 1.5 million Medicare Advantage members.

Is WellCare being bought out? ›

Centene Completes Acquisition of WellCare, Creating a Leading Healthcare Enterprise Focused on Government-Sponsored Healthcare Programs,” PR Newswire (January 23, 2020)

What is the difference between Aetna and WellCare? ›

One big difference between Aetna and Wellcare is that Wellcare only sells Medicare insurance, while Aetna also sells other types of insurance, such as group insurance and standalone vision and dental plans.

Was Aetna bought by WellCare? ›

We're glad you're here. WellCare Health Plans has acquired Aetna's standalone Medicare Part D Prescription Drug Plans (PDP).

Is GoodRx better than Medicare Part D? ›

GoodRx can also help you save on over-the-counter medications and vaccines. GoodRx prices are lower than your Medicare copay. In some cases — but not all — GoodRx may offer a cheaper price than what you'd pay under Medicare. You won't reach your annual deductible.

Who has the cheapest Part D drug plan? ›

SilverScript Medicare Prescription Drug Plans

Although costs vary by ZIP Code, the average nationwide monthly premium for the SmartRx plan is only $5.92, making it the most affordable Medicare Part D plan this carrier offers.

What is the best Medicare company to go with? ›

Best Medicare Supplement (Medigap) Companies of 2023
  • Best Overall: AARP / UnitedHealthcare.
  • Most Medigap Plan Types: Blue Cross Blue Shield.
  • Best Medigap High-Deductible Plan G Provider: Mutual of Omaha.
  • Lowest Cost High-Deductible Plan G: Humana.
  • Best for Financial Strength: State Farm.

What is the highest income to qualify for Medicaid 2022? ›

Income Limit in Most States

Most states — 38 and Washington, D.C. — have the same income limit of $2,523 per month for a single person for most types of Medicaid services. For a married couple, the limit increases to $5,046 in most cases.

Which state has the best Medicaid program? ›

States with the Best Medicaid Benefit Programs
RankStateTotal Spending Per Person
1New York$12,591
2New Hampshire$11,596
3Wisconsin$10,090
4Minnesota$11,633
46 more rows
16 Jun 2020

What happens if you don't make enough money to qualify for Obamacare? ›

Enroll on-exchange if your income is uncertain

Enroll in Medicaid if you're eligible. For people who aren't eligible for Medicaid but who have uncertain incomes, it's generally a good idea to enroll through the exchange during open enrollment.

What is the monthly income limit for Medicaid in Florida? ›

FLORIDA MEDICAID INCOME LIMITS 2021

Florida is an “Income Cap State,” which means that if an individual's gross income is more than $2,523 per month, that person is not eligible for Medicaid assistance.

What is the highest income to qualify for Medicaid? ›

Federal Poverty Level thresholds to qualify for Medicaid

For example, in 2022 it is $13,590 for a single adult person, $27,750 for a family of four and $46,630 for a family of eight. To calculate for larger households, you need to add $4,720 for each additional person in families with nine or more members.

How long is the waitlist for Medicaid waiver in Florida? ›

How long is the waiting list in Florida? Florida has almost as many people waiting for services as it serves. You can expect to wait 7 or more years before getting waiver services in Florida. How many people are on the waiting list in Florida?

What are the income limits for Medicaid 2022 in Florida? ›

In 2022, the medically needy income limit in FL is $180 / month for a single applicant and $241 / month for a married couple. The “spend-down” amount is the difference between one's monthly income and the medically needy income limit.

How long does it take to get approved for Medicaid in Florida? ›

It may take up to 30 days to process your application (longer if you need a disability determination). Visit What happens next to learn more.

Does WellCare own Sunshine Health? ›

Centene is the parent company of Sunshine Health; WellCare is the parent company of WellCare of Florida, Inc. Centene and WellCare will be bringing our health plans together to better serve our members, providers, partners and communities.

Did WellCare change their name? ›

Beginning Jan. 1, 2022, Centene's Medicare brands, including Allwell, Health Net, Fidelis Care, Trillium Advantage, 'Ohana Health Plan, and TexanPlus will transition to the Wellcare brand. For more information about Wellcare, visit www.wellcare.com.

Who did WellCare merge with? ›

in its merger with Centene Corporation (NYSE: CNC) for $17.3 billion. The combined company will serve more than 24 million members in all 50 states and will be headquartered in St.

How long has Sunshine Health been in business? ›

State-sponsored Medicaid benefits for eligible Floridians. Sunshine Health is a Florida Medicaid health plan that has been providing services in Florida since 2009.

Is WellCare a Chinese company? ›

Everyone at Wellcare has your best interest at heart to provide the best products to show we sincerely care. Headquartered in Taiwan, the two sisters established R&D, Marketing, QA departments in Taiwan and manufacturing facility in China, with markets all over Europe, America, and Asia.

What's the difference between Humana and WellCare? ›

Wellcare offers Medicare Part D prescription drug plans and Medicare Advantage plans in certain parts of the country. Humana, on the other hand, sells Part D plans, Medicare Advantage plans and Medicare Supplement Insurance (Medigap) plans.

What did Wellcare used to be called? ›

WellCare Health Plans, Inc.

What is another name for Wellcare? ›

Wellcare was founded in 1985 and became a subsidiary of Centene in 2020. The company's headquarters are in Tampa, Florida. Wellcare offers coverage through Medicaid, Medicare Advantage and Medicare prescription drug plans. As of October 2022, Centene covered nearly 1.5 million Medicare Advantage members.

Was Aetna bought by Wellcare? ›

We're glad you're here. WellCare Health Plans has acquired Aetna's standalone Medicare Part D Prescription Drug Plans (PDP).

What is the relationship between CVS and WellCare? ›

WellCare has about $15 to $20 billion in annual drug spending as part of its medical costs, and CVS is WellCare's PBM. Centene uses RxAdvance to negotiate drug prices for plan members, and Centene could plan to move the WellCare business onto its existing platform.

Who bought Humana? ›

The deal is also the fourth-largest consolidation in the American economy this year. Image of Aetna building from wikipedia. Aetna will pay $37 billion cash and stock to acquire Humana, the companies announced on July 3, in what will be the biggest health insurance merger to ever hit the industry.

What is the Sunshine Act in healthcare? ›

The Sunshine Act requires that detailed information about payments and other “transfers of value” worth over $10 from manufacturers of drugs, medical devices and biologics to physicians and teaching hospitals be made available to the public.

Does Walgreens accept Sunshine Health? ›

Members pay only 2.5 copays (save ½ a copay) when they fill eligible maintenance medications, 90 days at a time, at Walgreens starting January 1, 2022. If your patients currently fill their prescriptions at CVS retail pharmacies, please send or call in their scripts to any in-network pharmacy.

Does Medicaid cover surgery? ›

When it comes to surgical procedures, both Medicare and Medicaid provide coverage for many medically necessary surgical services received under inpatient and outpatient treatment. However, coverage terms can vary depending on the type of surgery being performed, where it is performed, and your specific circumstances.

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