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

More documents

Recommendations

Info

Standard XV: Immunizations, Pregnancy, Drugs & Transportation CONTRACT SECTION Chapter 468, F.S. Chapters 458 or 459, F.S. CC-V.H.15.m.1-8 19. Pregnancyrelated Requirements: Postpartum Care CC-V.H.15.n.1-3 20. Prescribed Drugs AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT REQUIREMENT COMPLIANT SCORING physician, such as the Healthy Start (postnatal) infant screen. • Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a physician licensed under Chapters 458 or 459, F.S., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist). The health plan: • Provides a postpartum examination for the enrollee within six (6) weeks after delivery. • Ensures that its providers supply voluntary family planning, including a discussion of all methods of contraception, as appropriate. • Ensures that continuing care of the newborn is provided through the CHCUP program component. The health plan: • Provides those products and services associated with the dispensing of medicinal drugs pursuant to a valid prescription, as defined in Chapter 465, F.S. Prescribed drug services generally include all prescription drugs listed in the Agency’s Preferred Drug List (PDL). • Has a PDL that includes at least two (2) products, when available, in each therapeutic DOCUMENTS REVIEWED FINDINGS State of Florida Compliance Monitoring_Standard_XV_F2_07_11 Yes No Yes No Met Partially Met Not Met Met Partially Met Not Met Page 11
Standard XV: Immunizations, Pregnancy, Drugs & Transportation CONTRACT SECTION Chapter 465, F.S. s. 409.91195, F.S. CC-V.H.16.a CC-V.H.16.a.1–16.a.5 21. Prescribed Drugs: PBA CC-V.H.16.b AGENCY FOR HEALTHCARE ADMINISTRATION MANAGED CARE ORGANIZATIONS Compliance Monitoring Tool with Specific Contract Standards CONTRACT REQUIREMENT COMPLIANT SCORING class. • Makes available those drugs and dosage forms listed in its PDL. • Does not arbitrarily deny or reduce the amount, duration or scope of prescriptions solely based on the enrollee’s diagnosis, type of illness or condition. • May place appropriate limits on prescriptions based on criteria such as medical necessity, or for the purpose of utilization control, provided the health plan reasonably expects said limits to achieve the purpose of the prescribed drug services set forth in the Medicaid State Plan. • Makes available those drugs not on its PDL, when requested and approved, if the drugs on the PDL have been used in a step therapy sequence or when other medical documentation is provided. • Submits an updated PDL to BMHC and the Bureau of Pharmacy Services by October 1 of each Contract year, and provides thirty (30) days’ written notice of any changes. If the health plan adopts the Medicaid PDL, the health plan is exempt from such reporting. Antiretroviral agents are not subject to the PDL. The health plan may delegate any or all functions to one (1) or more pharmacy benefits administrators (PBA). Before entering into a subcontract, the health plan works with the Agency’s fiscal agent. DOCUMENTS REVIEWED FINDINGS State of Florida Compliance Monitoring_Standard_XV_F2_07_11 Yes No N/A Met Partially Met Not Met Page 12
Page 3 and 4:
Attachment I Special Term and Condi
Page 5 and 6:
Attachment II Special Term and Cond
Page 7 and 8:
RICK SCOTT GOVERNOR 272 7 Mah an Dr
Page 9 and 10:
• Encounter data • Systems issu
Page 11 and 12:
Appendix A How to Become a Florida
Page 13 and 14:
How to Become a Florida Medicaid He
Page 15 and 16:
Appendix B MCO Application Checklis
Page 17 and 18:
4 5 6 7 8 9 10 Service Level(s) are
Page 19 and 20:
19 b. Total number of employees; AP
Page 21 and 22:
APPLICATION ITEM 25 3. In the past
Page 23 and 24:
32 33 34 35 36 APPLICATION ITEM 10.
Page 25 and 26:
APPLICATION ITEM C. Criminal Backgr
Page 27 and 28:
APPLICATION ITEM 43 13. For medical
Page 29 and 30:
46 47 APPLICATION ITEM 16. Indicate
Page 31 and 32:
49 APPLICATION ITEM 19. Describe in
Page 33 and 34:
51 52 53 54 55 56 APPLICATION ITEM
Page 35 and 36:
Attachment III Special Term and Con
Page 37 and 38:
RICK SCOTT GOVERNOR Regulatory Auth
Page 39 and 40:
e. Complete a credentialing review
Page 41 and 42:
RICK SCOTT GOVERNOR Regulatory Auth
Page 43 and 44:
Compliance Monitoring Tool with Spe
Page 45 and 46:
Standard I: Care Management/Continu
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Results for Standard I Care Managem
Page 53 and 54:
Standarrd II: Utilizatio on Managem
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Standard III: Eligibility, Enrollme
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Standard IV: Enrollee Services & En
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Results for Standard IV Enrollee Se
Page 105 and 106:
Standard V: Provider Credentialing
Page 107 and 108:
Standard VI: Provider Services CONT
Page 109 and 110:
Standard VI: Provider Services CC-
Page 111 and 112:
Standard VI: Provider Services CONT
Page 113 and 114:
Standard VII: Provider Contracting
Page 115 and 116:
AGENCY FOR HEALTHCARE ADMINISTRATIO
Page 117 and 118:
Standard VIII: Quality Improvement
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Results for Standard IX Medical Rec
Page 131 and 132:
Standard X: Access and Availability
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Results for Standard X Access and A
Page 147 and 148:
Standard XI: Grievances and Appeals
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Standard XII: Administration and Ma
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Results for Standard XII Administra
Page 191 and 192: Standard XIII: Community Outreach C
Page 203 and 204: Results for Standard XIII Community
Page 205 and 206: Standard XIV: Covered Services AGEN
Page 233 and 234: Standard XV: Immunizations, Pregnan
Page 241: Standard XV: Immunizations, Pregnan
Page 249 and 250: Vendor Name: Review Period: Date of
Page 253 and 254: Agency For Health Care Administrati
Page 255 and 256: File # Case ID # Agency For Health
Page 257 and 258: File # Case ID # 1 2 3 4 5 6 7 8 9
Page 261 and 262: 13 14 15 Agency For Health Care Adm
Page 265 and 266: f. Posting of the Agency Summary of
Page 267 and 268: Name: Review Period: Date of Review
Page 283 and 284: 5. 6. 7. 8. 9. local WIC office to
Page 289 and 290: 14 Agency For Health Care Administr
Page 293 and 294:
Vendor Name: Review Period: Date of
Page 295 and 296:
8 providers Agency For Health Care
Page 297 and 298:
Agency For Health Care Administrati
Page 299 and 300:
Page 301 and 302:
Page 303 and 304:
Page 305 and 306:
Page 307 and 308:
Page 309 and 310:
Page 311 and 312:
Page 313 and 314:
Page 315 and 316:
Page 317 and 318:
Page 319 and 320:
Page 321 and 322:
Page 323 and 324:
Page 325 and 326:
Page 327 and 328:
Page 329 and 330:
Medical Loss Ratio The following dr
Page 331 and 332:
RICK SCOTT GOVERNOR Better Health C
Page 333 and 334:
Plan Name: AGENCY FOR HEALTH CARE A
Page 335 and 336:
DRAFT ATTESTATION OF 201_ QUARTER E
Page 337 and 338:
Draft MLR Reporting Schedule Health
Page 339 and 340:
RICK SCOTT GOVERNOR PLAN TYPES: Bet
Page 341 and 342:
Attachment V Special Term and Condi
Page 343 and 344:
RICK SCOTT GOVERNOR Mission to Ensu
Page 345 and 346:
• Obtaining data from the health
Page 347 and 348:
RICK SCOTT GOVERNOR Mission to Ensu
Page 349 and 350:
Attachment VI Special Term and Cond
Page 351 and 352:
RICK SCOTT GOVERNOR Better Health C
show all

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

Create successful ePaper yourself

Delete template?

Save as template?