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

Standard XII: Administration and Management
CONTRACT
SECTION
11. REFORM:
Benefit
Maximum
Exhibit 2
12. Responsibilities
of the Health
Plan
CC-X.A.2
13. Centralized
Executive
Administration
CC-X.A.3
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
When the cost of an enrollee’s covered services
reaches the benefit maximum of $550,000 in a
fiscal year, the health plan assists the enrollee in
obtaining necessary health care services in the
community.
a. The health plan continues to coordinate the
care received by the enrollee in the
community, and the health plan continues to
be responsible for emergency services and
care.
b. In addition, the health plan provides benefit
reporting to BMHC, monthly, and HSD in
accordance with Attachment II, Section XII,
Reporting Requirements, once the cost of
covered services reaches $450,000.
The health plan is responsible for the
administration and management of all aspects of
this Contract, including, but not limited to,
delivery of services, provider network, provider
education, claims resolution and assistance, and
all subcontracts, employees, agents, and services
performed by anyone acting for or on behalf of
the health plan.
The health plan has a centralized executive
administration, which serves as the contact point
for the Agency, except as otherwise specified in
this Contract.
a. Yes
No
N/A
b. Yes
No
N/A
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XII_F2_07_11
Page 4