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

Standard III: Eligibility, Enrollment, and Disenrollment
Exhibit 3
CONTRACT
SECTION
30. Disenrollment
Not Subject to
an Appeal
CC-III.C.1.d
31. Disenrollment
for Enrollees
Subject to Open
Enrollment
42 CFR 438.56(c)(2)(i)
CC-III.C.1.e
32. Dissenrollment
for Enrollees
Not Subject to
Open
Enrollment
42 CFR 438.56(c)(2)(ii)
CC-III.C.1.e
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
c. Being a sibling of a sole beneficiary
who is no longer eligible for
enrollment in the health plan due to a.
or b. above.
The health plan ensures that enrollees who are
disenrolled and wish to file an appeal have the
opportunity to do so. All enrollees are afforded
the right to file an appeal of disenrollment
except for the following reasons:
a. Moving out of the service area.
b. Loss of Medicaid eligibility.
c. Determination that an enrollee is in an
excluded population.
d. Enrollee death.
An enrollee subject to open enrollment may
submit to the Agency or its agent a request to
disenroll from the health plan. Disenrollment
may occur without cause during the 90
calendar day change period following the date
of the enrollee’s initial enrollment with the
health plan, or the date the Agency or its agent
sends the enrollee notice of the enrollment,
whichever is later.
An enrollee may request disenrollment
without cause every 12 months thereafter
during the annual open enrollment period.
Those not subject to open enrollment may
disenroll at any time.
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
Yes
No
Yes
No
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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