Important News for All Medicaid Enrollees
The following information is for our patients enrolled in Medicaid health coverage, including Sunshine Health, Simpy Healthcare, CMS, Medicaid, and UHC Community. This information does not apply to Tricare, which is not a Medicaid plan.
Medicaid redetermination resumed in April 2023 and continues over the next 12 months.
Medicaid redetermination is a process used by the states to ensure that Medicaid members are still eligible for Medicaid coverage. States are required to periodically redetermine member eligibility and to disenroll those who no longer meet the eligibility guidelines.
Medicaid enrollees are required to verify eligibility or risk losing Medicaid coverage. In Florida, the Department of Children and Families determines eligibility for Medicaid.
PLEASE NOTE: Pediatric Health Care Alliance does not have any role in the Medicaid eligibility process. We are sharing this information to help increase education and awareness for our patients about these upcoming changes.
If you have questions about your Medicaid renewal or eligibility, please contact the Member Services number listed on your insurance card.
Medicaid MMA Plans
If you are selecting a Medicaid plan and would like to join our practice, please note that we only participate Sunshine Health and Simply Healthcare*.
*Note - we do not accept Florida Healthy Kids, which is a separate plan administered by Florida KidCare.
Our offices are limited in the number of patients we can accept on these plans, and there are times when some locations are not able to accept new patients.
Status as of October 2022:
- The following offices are closed to new patients with Simply Health or Sunshine Health plans. Families with established patients should contact the office about adding a new sibling.
- Closed: Apollo Beach, Big Bend, South Tampa, Wesley Chapel
- All other PHCA offices are accepting new patients on these plans.
Affordable Care Act (ACA) / Marketplace Plans
We receive many inquiries regarding the ACA and whether we accept any of the marketplace plans. It is up to the managed care companies if they choose to include us in the network for any plan, and we are not always notified or given specific plan names. Even if we are contracted with a major managed care company (e.g. United HealthCare, Humana, etc.) that does not mean we are included in all of their plans, including marketplace plans. Each company can have hundreds of plans, and each of those plans can have different provider networks included.
Our recommendation to patients is to check the participating providers listed for any plan you are considering. If our pediatricians are not listed, that means the plan has not included PHCA in their network.
Please Note: If PHCA is not listed on a plan you are considering, be aware that plan may have a narrow network that does not include a variety of providers and may not cover a full range of benefits and services.
Insurance and Billing Policy
- For every office visit, please bring your most recent insurance card to ensure the information is valid at the time of service. Incorrect or out-of-date information can delay your claim and you may be held responsible for full payment of the claim.
- Your insurance card is similar to a driver's license or credit card - the information must be valid in order for it to be used.
- The insurance companies do not supply us with claim forms or policy numbers. If your insurance company requires specific forms, it is your responsibility to provide them to our office.
- We must emphasize we cannot accept responsibility for collecting or negotiating insurance claims. We will gladly assist in completion of required additional forms and supplying additional information and/or patient records. As a reminder, billing a health insurance provider on your behalf is a courtesy we provide to our patients.
Please review our Billing Guidelines for more information.
Payment Policy
At all Pediatric Health Care Alliance offices, payment is due at time of service and is collected at check-in. This includes co-pay, co-insurance, deductible, and/or any outstanding balance on the account. Payment may be made with cash, check, or major credit card.