Sunshine Health Launches ABA Performance Incentive Program: Is Your Agency Ready? ENG

Sunshine Health (Florida Medicaid plan) will implement a value-based performance program for Behavior Analysis (BA) services. This program rewards BA providers who deliver measurable, high-quality outcomes, focusing on delivering the recommended therapy hours according to each child’s needs.

The goal is to move from a volume-based model to a value-based model, incentivizing clinical best practices and proper service delivery to optimize outcomes for children (for example, children with autism spectrum disorder or other conditions).

In essence, payment is aligned with quality and impact of care: providers who meet nationally recommended therapy hours (according to the child’s age and diagnosis) will be financially rewarded. Below are the key aspects of the program, organized by section for clarity.

Performance Levels and Bonus Structure (Tiers)

The program defines three performance tiers based on the provider’s percentage of compliance with recommended therapy hours per member. Each tier carries a different bonus or incentive:

• Tier 1: Compliance ≥ 98% of recommended hours → Bonus: 100% of Medicaid rate (an additional payment equal to the standard Medicaid reimbursement). This is the highest level, with the maximum bonus.

• Tier 2: Compliance 95–97% → Bonus: 90% of Medicaid rate (an additional payment equal to 90% of the standard Medicaid reimbursement).

• Tier 3: Compliance 90–94% → No monetary bonus, but the provider is designated as a “Preferred Provider”within Sunshine Health (a recognition that may enhance status in the network, though with no extra pay).

⚠️ Compliance below 90% of recommended hours does not qualify for any bonus or recognition. In other words, 90% is the minimum threshold for incentives.

As seen above, Tier 1 can effectively double the Medicaid reimbursement for those services (by receiving an additional 100% bonus), while Tier 2 provides a somewhat smaller bonus (90%). Tier 3 offers no financial bonus but does provide a preferred status. Sunshine emphasizes that these incentives are not designed to limit care: the program does not reward the reduction of medically necessary services, and no incentive exists for denying care. All services must be delivered according to appropriate clinical standards.

Retroactive Payment Calculation and Adjustments

Bonuses are not paid with each claim but are calculated retroactively after evaluating the provider’s performance during the relevant period.

In practice:

• Sunshine Health will initially pay BA claims at the standard base rate.

• After quarterly review, Sunshine will adjust those claims retroactively to add the payment differential corresponding to the tier achieved.

For example:

• A provider qualifying for Tier 1 (100%) will receive an additional payment so that, combined with the base payment already received, it equals an extra 100% of Medicaid rates for that period.

• A provider qualifying for Tier 2 (90%) will receive an additional payment bringing them up to the 90% bonusamount.

In short: the calculation is deferred until the end of the quarter, and bonuses are then paid retroactively.

This means providers must submit all BA claims correctly and on time, since the measurement is based on submitted claims, and bonus payments depend on those data. Sunshine explicitly states: “Claims will be retroactively adjusted” to reflect the achieved bonus tier.

Clinical Documentation and Audit Requirements

Participation requires strict compliance with clinical documentation rules and readiness for audits. Since performance is measured by therapy hours claimed, it is crucial that session documentation and corresponding billing are accurate.

All claimed services must be supported by:

• Progress notes

• Updated treatment plans

• Medical necessity evidence

• Other Medicaid/Sunshine requirements

Audit rights:

• Sunshine Health (and state/federal agencies) may audit provider records to verify services delivered and compliance.

• Agencies must maintain complete, accurate records (e.g., service logs, signatures, authorizations) since they may be requested during an audit to confirm hours provided and adherence to guidelines.

⚠️ Sunshine makes it clear: all services must be medically necessary and delivered according to professional standards. Fraud, abuse, or overpayments will not be tolerated. If audits reveal improper payments (e.g., billing errors), Sunshine may recover or withhold bonus payments to offset those amounts.

In summary: accurate documentation and strict billing compliance are essential to participate and retain bonuses.

Program Eligibility Criteria

To participate and receive incentives, providers must meet specific criteria.

1. Scope: Applies only to BA providers serving Medicaid members in Sunshine Health’s MMA, SMI, and HIV programs.

2. Retroactive adjustments: Claims will be adjusted retroactively to apply the payment differential for the tier achieved.

3. Good standing requirement: Providers must remain in “good standing” with Sunshine Health throughout the program. This means:

   • Maintaining an active provider agreement (direct or through a vendor/IPA) from program start through bonus payment dates.

   • Complying with all contract terms, including completing any required training/education (e.g., Ethics, Fraud & Abuse, EPSDT).

   • Having no sanctions, remediation status, or contract termination in process.

4. No duplication with other incentive programs: The BA bonus is in addition to base compensation, but Sunshine may exclude providers already receiving overlapping quality incentives through other contracts.

5. Contract & audit compliance: All terms of the provider agreement apply, including audit rights by Sunshine/authorities.

6. Discretionary and no appeal rights: Sunshine reserves full discretion over program operation and payments. Providers have no right to appeal decisions under this program.

7. Overpayment offsets: Sunshine may withhold or offset bonuses if a provider has received or retained overpayments (due to error, fraud, or abuse).

8. No incentive to reduce services: Sunshine will not pay bonuses that encourage providers to limit medically necessary services.

What Does “Good Standing” Mean?

Being in “good standing” with Sunshine Health means:

• Keeping your provider contract active and uninterrupted throughout the program.

• Meeting all contract obligations: updated credentials, service standards, completion of required trainings.

• Having no unresolved sanctions, repeated serious complaints, or compliance remediation.

In simple terms: up-to-date, compliant, and problem-free. Only providers in good standing may participate and remain eligible for bonuses.

Exclusions for Providers in Other Incentive Programs

While the BA Value-Based Program is compatible with some incentives, Sunshine reserves the right to exclude providers already under other performance-based contracts to avoid duplicate payments.

• Agencies already in a different Sunshine incentive program (e.g., via IPA or other arrangements) may be excluded.

• For most ABA agencies not in such programs, this will not be an issue — participation is automatic.

Recommended Hours by Age & Diagnosis

A central component of the program is defining optimal weekly BA therapy hours by age and diagnosis, based on nationally recognized guidelines. These serve as benchmarks for evaluating compliance:

• Children under 4 years: 30–40 hours/week

• Children 4–6 years: 20–30 hours/week

• Children 7–12 years: 10–15 hours/week

• Adolescents 13+ years: 5–10 hours/week (focused on functional skills & transition goals)

Providers delivering close to 100% of these recommended hours for each child will achieve higher compliance percentages and qualify for higher bonus tiers.

⚠️ Note: These are general recommendations. Under Medicaid EPSDT, all medically necessary hours must still be authorized and covered. The program encourages alignment with best-practice ranges, but each child’s hours must be clinically justified and authorized individually.

Performance Review & Bonus Payment Timeline

Performance will be evaluated quarterly, with 3-month run-out periods to capture late claims before finalizing results.

• Q3 2025 (Jul–Sep): Run-out until Dec 31, 2025 → Bonus payment estimated Jan 2026

• Q4 2025 (Oct–Dec): Run-out until Mar 31, 2026 → Bonus payment estimated Apr 2026

Going forward, each quarter will follow the same cycle: service period → run-out → payout the following quarter.

Providers will also receive support:

• Provider Engagement Account Managers: assigned to agencies to review metrics and guide improvement.

• Provider Town Halls (BA-specific): covering best practices, billing, and program details.

Conclusion

The Medicaid BA Value-Based Performance Program from Sunshine Health is a detailed initiative rewarding ABA agencies for delivering the optimal amount of therapy to children, ensuring quality and alignment with clinical guidelines.

In return, Sunshine offers significant performance-based bonuses, calculated transparently from claims.

To succeed, agencies must:

• Remain in good standing with Sunshine Health

• Rigorously document services

• Deliver recommended therapy hours when clinically appropriate

This program represents both an opportunity (higher revenue, recognition) and a compliance challenge (strict documentation, audits).

NQCABA: Your Compliance Ally with Sunshine Health

In this new landscape, precise, error-free documentation is no longer optional — it’s mandatory.

NQCABA.com was built to help ABA agencies:

• Verify notes before submission

• Detect inconsistencies or errors automatically

• Ensure alignment with client profiles and approved programs

• Prevent denials, payment rejections, or negative audit findings

Our system analyzes each note and generates a section-by-section quality report: ABC, reinforcers, replacements, grammar issues, and more.

With NQCABA, agencies can strengthen compliance, safeguard payments, and maximize their ability to benefit from Sunshine Health’s Value-Based Program.