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

RICK SCOTT
GOVERNOR
Mission to Ensure Quality Care:
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T al l a has s ee, F L 3 23 08
Better Health Care for all Floridians
ELIZABETH DUDEK
SECRETARY
The Agency’s mission is to ensure quality care is provided to Florida’s residents. On occasion,
market fluctuations result in a Medicaid health plan leaving a county, terminating its contract, or
being purchased by another entity. Our primary goal when a Medicaid beneficiary faces such
change is to ensure continuity of care. The following is a summary of the processes and
requirements established to enable us to reach this goal.
Overview of Health Plan Requirements:
When a health plan decides to withdraw from a county, terminate its contract, or sell their book
of business to another entity, the health plan must provide written notice to the Agency at least
120 days prior to the anticipated effective date and must cease community outreach activities
as specified in the contract. Our model contract also allows the Agency to extend the
termination/transition effective date depending on the volume of health plan enrollees affected.
In addition, 60 days prior to the withdrawal date, the Agency halts enrollment of new members
into the health plan.
The health plan is required to work with the Agency to ensure a smooth transition for enrollees,
particularly those in the hospital, under case management, or with complex medication needs.
The health plans are contractually obligated to provide the Agency with any data needed to plan
for the transition. Frequently requested data includes listings of high-risk pregnancies, members
currently in the hospital, and members in active behavioral health care.
Enrollee Notifications:
Regardless of scenario, enrollees receive at least two written notifications of the upcoming
change, with an explanation of how to select another health plan.
At least 60 days prior to the transition effective date, the health plan must send an Agency-
approved letter to all its members. These member notices must include the date on which the
health plan will no longer participate in the state’s Medicaid program and instructions on
contacting the Agency’s choice counseling/enrollment broker toll-free help line to obtain
information on enrollment options or to request a change in health plans.
The Agency sends a second letter to impacted beneficiaries at least 30 days prior to the
transition date. If an affected enrollee contacts the choice counseling/enrollment broker to
select a new health plan 30 days prior to transition date, the Agency’s letter simply confirms the
choice and the effective date of enrollment into the new health plan. If an affected enrollee
does not select a new health plan 30 days prior to transition date, the Agency will assign a new
plan and send a notification letter to the enrollee with information on the new plan enrollment
and how to contact the Agency’s toll-free help line to request a change in health plans prior to
the enrollment effective date.
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