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

RICK SCOTT
GOVERNOR
Mission to Ensure Quality Care:
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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,
a provider leaves a health plan’s network. Our primary goal when a Medicaid beneficiary faces
such change is to ensure continuity of care. The following is a summary of the requirements
established to enable us to reach this goal.
Pertinent Model Contract Cites:
Attachment II, Section VII, Item C., Network Changes
Attachment II, Section VII, Item D., Provider Contract Requirements
Attachment II, Section VII, Item E., Provider Termination
Attachment II, Section VII, Item G., Continuity of Care
Overview of Health Plan Requirements:
Health plans are required to notify the Agency of terminated providers, regardless of whether
the plan or the provider initiates the termination. Health plans must also submit monthly reports
listing terminated providers and providing documentation that enrollee notices were distributed
in accordance with contract requirements.
Provider agreements between the health plan and its providers contain protections for enrollees,
as well. By signing a provider agreement, a provider agrees to give the health plan ninety days’
notice prior to terminating his/her agreement. This allows the health plan to notify enrollees and
transition their care to other providers as appropriate.
Enrollee Notifications:
Regardless of scenario, enrollees receive notice when one of their providers terminates from the
health plan. When a primary care provider (PCP) ceases participation with a health plan, the
enrollee notice must be issued by the health plan within fifteen calendar days after receipt of the
termination notice. When the health plan initiates the termination, it must notify enrollees in
active care at least sixty days before the effective date of the termination.
Provider Termination Policy Details:
Enrollees whose PCP is terminating may change PCPs immediately. They do not have to wait
until the termination takes effect.
To minimize any disruption to the enrollees, health plan provider agreements must require
providers of transitioning enrollees to cooperate in all respects with providers of other health
plans to assure maximum health outcomes for enrollees.
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