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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
3. Accepting
Medicaid
Recipients
CC-III.B.1.c
4. Nondiscrimination
CC-III.B.1.c
5. Maximum
Enrollment
Levels
CC-III.B.1.d
6. Verifying the
County of
Residence
CC-III.B.1.e
CC-III.C.5
7. Enrollees
Changing
County of
Residence
CC-III.B.1.e
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan accepts Medicaid recipients
without restriction and in the order in which
they enroll.
The health plan does not discriminate on the
basis of religion, gender, race, color, age, or
national origin, health status, pre-existing
condition, or need for health care services and
does not use any policy or practice that has the
effect of such discrimination.
The health plan accepts new enrollees
throughout the contract period up to the
authorized maximum enrollment levels.
Each month the health plan reviews the X12-
834 enrollment files:
a. To ensure that all enrollees reside in the
same county in which they were enrolled.
b. To determine which enrollees were
disenrolled due to moving outside the
service area.
The health plan updates the records for all
enrollees who have moved from one county to
another but are still residing in the health
plan’s service area and provides those
enrollees with a new provider directory for
that county, if necessary.
Yes
No
Yes
No
Yes
No
a. Yes
No
b. Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_III_F2_07_11
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