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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
42 CFR 438.56(d)(2)(i-iv)
42 CFR 438.702(a)(3)
CC-III.C.3.a
39. Voluntary
Enrollee
Disenrollment
42 CFR 438.59(c)(1)
CC-III.C.3.b
40. Fraudulent Use
of ID Card
CC-III.C.4.a.1
41. Reasons for
Involuntary
Disenrollment
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
i. Poor quality of care.
ii. Lack of access to services covered
under the contract.
iii. Inordinate or inappropriate changes
of PCPs.
iv. Service access impairments due to
significant changes in the geographic
location of services.
v. Lack of access to providers
experienced in dealing with the
enrollee’s health care needs.
vi. Fraudulent enrollment.
Voluntary enrollees may disenroll from the
health plan at any time.
With proper written documentation, the
following are acceptable reasons for which the
health plan may submit involuntary
disenrollment requests to the Agency or its
agent:
Fraudulent use of the enrollee ID card (the
health plan must report the event to MPI).
In addition to #38, with proper written
documentation, the following are acceptable
reasons for which the health plan may submit
involuntary disenrollment requests to the
Agency or its agent:
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. 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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