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

Standard I: Care Management/Continuity of Care
CONTRACT
SECTION
Management
Policies and
Procedures
Exhibit 8
20. REFORM
except
HIV/AIDS:
Transitioning
Enrollees
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
Standards and Guidelines, which may be
accessed online at http://web.ncqa.org/tabid/
381/Default.aspx.
a. In addition to policies and procedures,
the health plan has a disease
management program description for
each disease state that describes how the
program fulfills the principles and
functions of each of the NCQA Disease
Management Standards and Guidelines
categories.
b. Each program description also describes
how enrollees are identified for
eligibility and stratified by severity and
risk level.
c. The health plan submits a copy of its
policies and procedures and program
description for each of its disease
management programs to BMHC by
April 1 of each Contract year.
The health plan has a policy and procedure
regarding the transition of enrollees from
disease management services outside the
health plan to the health plan’s disease
management program.
a. This policy and procedure includes
coordination with the disease
management organization (DMO) that
provided services to the enrollee before
N/A
c. Yes
No
N/A
a. Yes
No
N/A
b. Yes
No
N/A
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_I_F2_07_11
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