Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Standard X: Access and Availability
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
42 CFR 438.206
CC-VII.A.6.a-e
6. Out-of-Network
Providers
42 CFR 438.206(b)(4)
CC-VII.A.7
7. Second Opinion
42 CFR 438.206
CC-IV.G.6
8. Enrollee Choice of
Network Providers
CC-VII.A.8
9. Refusing to Accept
Providers
CC-VII.A.10
enrollees.
e. The geographic location of
providers and enrollees,
considering distance, travel time,
the means of transportation
ordinarily used by enrollees and
whether the location provides
physical access for Medicaid
enrollees with disabilities.
If the health plan is unable to provide
medically necessary services to an
enrollee, the health plan covers the
services in an adequate and timely
manner by using providers and
services that are not in the health
plan’s network for as long as the health
plan is unable to provide the services
within its network.
The health plan must provide for a
second opinion from a qualified health
care professional within the network,
or arrange for the enrollee to obtain
one outside the network, at no cost to
the enrollee.
The health plan allows each enrollee to
choose among network providers to
the extent possible and appropriate.
If the health plan declines to include
individual providers or groups of
providers in its network, it must give
the affected providers written notice of
the reason for its decision.
Yes
No
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_X_F2_07_11
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