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 Found in Handbook Reference Comments
The enrollee handbook contains:
32
33
34
Total # Applicable Elements
Total # Compliant Elements
Total Percent Compliant
Instructions concerning how to get information to help the enrollee assess
a potential behavioral health problem.
Information concerning behavioral health.
a. The extent to which and how after-hours and emergency coverage is
provided and that the enrollee has a right to use any hospital or other
setting for emergency care.
b. Information that post-stabilization services are provided without prior
authorization and other post stabilization care services rules.
c. A clear statement that the enrollee may select an alternative
behavioral health care manager or direct service provider within the
health plan, if one is available.
d. A description of behavioral health services provided, including
limitations, exclusions and out-of-network use.
e. A description of emergency behavioral health services procedures
both in and out of the health plan’s service area.
Instructions concerning how to get information about the structure and
operation of the health plan and any physician incentive plans.
Managed Care Organizations Page 7
Enrollee Handbook Audit Tool F2_05_10
Florida Medicaid
Y N
a. Y N N/A
b. Y N N/A
c. Y N N/A
d. Y N N/A
e. Y N N/A
Y N
42 CFR 438.10(g)(3)
CC-IV.A.6.a.26
CC-IV.A.6.a.28
42 CFR 438.10(g)(3)
CC-IV.A.6.a.27