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

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APPLICATION ITEM
e. List the name of any person or corporation listed in any of the
above paragraphs who is required to be listed on the CMS
Disclosure of Ownership and Control Interest Statement because
of an ownership, control or management interest in another
applicant, Medicaid provider service network or Medicaid
managed care organization currently contracted to provide
Medicaid services in Florida. Indicate if any of the persons
named are related to another named person as spouse, parent,
child or sibling.
f. List any subcontractors, participating providers or suppliers
owned by the applicant, its management, its owners or any
members of its board of directors including the percent of
financial interest.
g. List subcontractors, participating providers or suppliers, with
whom the applicant has had business transactions totaling more
than $25,000 during the 12 months preceding the date of the
application.
h. List the name of each officer, director, agent or owner of the
applicant or its affiliates, who is an employee of the State of
Florida or any of its agencies. Denote the percent of financial
interest in the contracting applicant held by the individual. See
model Contract Attachment II, Section XVI, Item V.2. and 3. for
more details.
Agency for Health Care Administration
Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
If any owners are also involved with other health
plans, ensure staffing is adequate and no
inappropriate sharing of key staff, listed in X.A.,
Staffing, of the application exists. If inconsistencies
or unclear, alert and discuss with administrators.
If major subcontractors appear to be owners, alert
and discuss with administrator.
See relative to #39 as well.
Confirm the subcontracted vendors are not owned
by the health plan owners at
http://www.sunbiz.org/corpweb/inquiry/search.html:
Print website screen prints used for confirmation
and keep with the checklist.
RED FLAG: If applicant reports such ownership,
discuss with administrators.
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 9 of 19
INITIALS &
DATE
COMPLETED