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

Standard XII: Administration and Management
Exhibit 5
CONTRACT
SECTION
63. REFORM
CAPITATED:
Exhaustion of
Benefits Letters
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
sufficiency standards no later than June 15 th of
each year.
The health plan incorporates a requirement into
its policies and procedures stating that it will
send letters of notification to enrollees regarding
exhaustion of benefits for services restricted by
unit amount if the amount is more restrictive than
Medicaid for the following services: pharmacy;
DME; hospital outpatient services not otherwise
specified (NOS) and hospital outpatient physical,
occupational, respiratory, and speech therapy
services; hearing services; vision services;
chiropractic; podiatry; and home health services.
The health plan sends an exhaustion of benefits
letter for any service restricted by a dollar
amount. The health plan implements said letters
upon the written approval of the Agency. The
letters of notification include the following:
a. A letter notifying an enrollee when
he/she has reached fifty percent (50%) of
any maximum annual dollar limit
established by the health plan for a
benefit.
b. A follow-up letter notifying the enrollee
when he/she has reached seventy-five
(75%) of any maximum annual dollar
limit established by the health plan for a
benefit.
c. A final letter notifying the enrollee that
a. Yes
No
N/A
b. Yes
No
N/A
c. Yes
No
N/A
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XII_F2_07_11
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