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

Standard XIV: Covered Services
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
CC-V.H.10.a.10
33. NON- REFORM:
Inpatient Hospital
Services: 45 Days of
Inpatient Coverage
CC-V.H.10.a.10
34. CAPITATED: Nursing
Home Services vs.
Inpatient Services
Exhibit 5
35. REFORM CAPITATED
PLANS: Transplants
CC-V.H.10.a.6
CC-V.H.10.b.1
36. NON-REFORM:
Transplants: Payments
to Plans
health (if behavioral health is covered by the
health plan as specified in Attachment I), in
accordance with the Medicaid Hospital
Services Coverage & Limitations Handbook,
for each state fiscal year.
For non-Reform populations, the health plan
provides up to forty-five (45) days of inpatient
coverage per enrollee, including behavioral
health (if behavioral health is covered by the
health plan as specified in Attachment I), for
each state fiscal year.
The health plan may provide services in a
nursing home as downward substitution for
inpatient services. Such services are not
counted as inpatient hospital days.
For transplant services of the heart, liver, or
lung, Reform capitated health plans are paid
by the Agency through kick payments. (See
Summary of Responsibility Table Section
5.H.10.a.6)
Transplant services for non-reformed health
plans of the heart, liver, or lung as well as preand
post-transplant follow-up care, are covered
through fee-for-service Medicaid and not by
the health plan. All other transplants are paid
by the health plan.
If at the conclusion of the transplant evaluation
the enrollee is listed with the United Network
for Organ Sharing (UNOS) as a level 1A, 1B,
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XIV_F3_07_11
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
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