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

Standard XII: Administration and Management
CONTRACT
SECTION
9. CAPITATED
REFORM
PLANS:
Compliance with
Florida Medicaid
Handbooks
Exhibit 2
10. FFS PSNs and
CAPITATED
REFORM:
Catastrophic
Component
Threshold
Exhibit 2
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan complies with all current Florida
Medicaid Handbooks (Handbooks) pursuant to
Attachment II, Section II, General Overview,
unless a customized benefit package has been
certified by the Agency.
a. In no instance may the limitations or
exclusions imposed by the health plan be
more stringent than those specified in the
Handbooks, unless authorized in the
customized benefit package by the Agency.
b. The health plan may exceed limits in the
Handbooks by offering expanded services, as
described elsewhere in this Contract or
through its approved customized benefit
package.
A health plan that accepts only the
comprehensive component of the capitation rate
continues to provide all covered services to each
enrollee who reaches the catastrophic component
threshold.
a. The health plan continues to apply its QM
and UM program components, as well as
other administrative policies and protocols to
the delivery of care and services to the
enrollees who meet the threshold.
b. The health plan submits documentation for
reimbursement for covered services costs as
outlined in Attachment II, Exhibit 13.
a. Yes
No
N/A
b. Yes
No
N/A
a. Yes
No
N/A
b. Yes
No
N/A
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XII_F2_07_11
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