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

Standard XII: Administration and Management
CONTRACT
SECTION
59. REFORM
CAPITATED:
Approved CBPs
Exhibit 5
60. REFORM
CAPITATED:
Sufficiency
Testing the CBP
Exhibit 5
61. REFORM
CAPITATED:
Maximum
Annual Dollar
Value of the CBP
Exhibit 5
62. REFORM
CAPITATED:
Changing the
CBPs
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
Approved CBPs must comply with the benefit
grid plan evaluation tool and instructions
available from HSD. The Agency tests the health
plan’s CBP for actuarial equivalency and
sufficiency of benefits, before approving the
CBP. Actuarial equivalency is tested by using a
benefit plan evaluation tool that:
a. Compares the value of the level of benefits in
the proposed package to the value of the
current Medicaid State Plan package for the
average member of the covered population.
b. Ensures that the overall level of benefits is
appropriate.
Sufficiency is tested by comparing the proposed
CBP to state-established standards. The
standards are based on the covered population’s
historical use of Medicaid State Plan services.
These standards are used to ensure that the
proposed CBP is adequate to cover the needs of
the vast majority of the enrollees.
If, in its CBP, the health plan limits a service to a
maximum annual dollar value, the health plan
must calculate the dollar value of the service
using the Medicaid fee schedule.
The CBPs may change on a Contract year basis
and only if approved by the Agency in writing.
The health plan submits to HSD its CBP for
recertification of actuarial equivalency and
a. Yes
No
N/A
b. Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
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_XII_F2_07_11
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