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

Standard XIII: Community Outreach
CONTRACT
SECTION
26. Prohibited:
Paying
Commission
Related to
Enrollment
CC-IV.B.2.r
27. Prohibited:
Activities
Listed in s.
641.3909. F.S.
s.641.3903, F. S.
CC-IV.B.2.s
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan is prohibited from engaging in
paying commission compensation to community
outreach representatives for new enrollees. The
payment of a bonus to a community outreach
representative is not considered a commission if
such bonus is not related to enrollment or
membership growth.
The health plan is prohibited from engaging in
all activities included in:
a. Misrepresentation and false advertising of
health maintenance contracts.
b. Providing false information or false
advertising.
c. Defamation.
d. Making false statements and entries.
e. Unfair claims settlement practices.
f. Failure to maintain complaint-handling
procedures.
g. Operation without a subsisting certificate of
authority.
h. Misrepresnetation in HMO applications.
i. Twisting.
j. Illegal dealings in premiums and excess or
reduced charges for HMO coverage.
k. False claims and obtaining or retaining
money dishonestly.
l. Prohibited discriminatory practices.
m. Misrepresentation concering the availability
of HMO providers.
n. Adverse actions against a provider.
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
g. Yes
No
h. Yes
No
i. Yes
No
j. Yes
No
k. Yes
No
l. Yes
No
m. Yes
No
n. Yes
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XIII_F2_07_11
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