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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
42 CFR
438.56(c)( 2)
CC-III.C.2
37. MANDATORY
ENROLLEES:
Requesting
Disenrollment
42 CFR 438.56 (c)(1)
CC-III.C.3.A
38. Cause for
Disenrollment
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
b. At least every 12 months.
c. If the temporary loss of Medicaid eligibility
has caused the enrollee to miss the open
enrollment period.
d. When the agency or its agent grants the
enrollee the right to terminate enrollment
without cause (done on a case-by-case
basis).
e. REFORM ONLY: If the individual
chooses to opt out and enroll in an
employer-sponsored health plan.
f. Without cause, for enrollees not subject to
open enrollment, at any time.
A mandatory enrollee may request
disenrollment from the health plan for cause at
any time. Such request is submitted to the
Agency or its agent.
The following reasons constitute cause for
disenrollment from the health plan:
a. The enrollee moves out of the county, or
the enrollee’s address is incorrect and the
enrollee does not live in a county where
the health plan is authorized to provide
services.
b. The provider is no longer with the health
plan.
c. The enrollee is excluded from enrollment.
d. A substantiated marketing or community
Yes
No
N/A
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
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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