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

Agency For Health Care Administration
Managed Care Organizations
Enrollee Handbook Audit Tool
Enrollee Handbook Review Tool
Item Number Standard
The enrollee handbook contains:
Emergency services and procedures for obtaining services both in and out
of the health plan’s service area including:
Found in Handbook Reference Comments
a. An explanation that prior authorization is not required for
9
b.
emergency or post-stabilization services
Locations of emergency settings and other locations at which
providers and hospitals furnish emergency services and poststabilization
care services
a. Y
b. Y
c. Y
d. Y
N
N
N
N
42 CFR 422.133(c)
CC-IV.A.6.a.1
c. Use of 911 or its local equivalent
d. Post-stabilization requirements
10
11
12
13
The extent to which, and how, after-hours and emergency coverage is
provided, and that the enrollee has the right to use any hospital or other
setting for emergency care.
Information concerning the:
a. Extent to which and how enrollees may obtain services from
out-of-network providers
b. Right to obtain family planning services from any participating
Medicaid provider without prior authorization
Information about the Subscriber Assistance Program (SAP, for HMOs
only) and the Beneficiary Assistance Program (BAP, for PSNs only), and
the Medicaid Fair Hearing Process, including an explanation that a review
by the SAP must be requested within 1 year after the date of the
occurrence that initiated the appeal, how to initiate a review by the SAP
and the SAP address and telephone number:
Agency for Health Care Administration SAP/BAP
Building 1, MS #26,
2727 Mahan Drive
Tallahassee, FL 32308
(805) 921-5458 or (888) 419-3456 (toll free)
Clear specifications about the grievance process including:
a. Address.
b. Telephone number.
c. Office hours of the grievance staff
Managed Care Organizations Page 2
Enrollee Handbook Audit Tool F2_05_10
Florida Medicaid
Y N
a. Y N
b. Y N
CC-IV.A.6.a.10
42 CFR 438.100
CC-IV.A.6.a.11
Y N CC-IV.A.6.a.12
a. Y N
b. Y N
c. Y N
d. Y N
CC-IV.A.6.a.13