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

Vendor Name:
Review Period:
Date of Review:
Reviewer:
Participating Vendor Staff Member:
Agency For Health Care Administration
Managed Care Organizations
Enrollee Handbook Audit Tool
Enrollee Handbook Review Tool
Item Number Standard Found in Handbook Reference Comments
The enrollee handbook contains:
1 Table of Contents Y N CC-IV.A.6.a.1
2
3
Terms, conditions, and procedures for enrollment including the
reinstatement process and enrollee rights and protections.
A description of the 90-day change period and the open enrollment
process.
Y N CC-IV.A.6.a.2
Y N CC-IV.A.6.a.3
4 Information about how to change PCPs. Y N CC-IV.A.6.a.4
5
6
7
Description of services provided, including:
a. Limitations and general restrictions on provider access
b. Exclusions
c. Out-of-network use
d. Any restrictions on enrollee freedom of choice among network
providers
Procedures for obtaining required services including:
a. Second opinions
b. Authorization requirements
c. Services available without prior authorization
Information regarding newborn enrollment, including the mother’s
responsibility to notify the health plan and DCF of the pregnancy and the
newborn’s birth.
a. Y N
b. Y N
c. Y N
d. Y N
a. Y N
b. Y N
c. Y N
CC-IV.A.6.a.5
CC-IV.A.6.a.6
Y N CC-IV.A.6.a.7
8 Information concerning how to select the newborn’s PCP. Y N CC-IV.A.6.a.8
Managed Care Organizations Page 1
Enrollee Handbook Audit Tool F2_05_10
Florida Medicaid