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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
42 CFR 438.56(b)(1-2)
CC-III.C.4.a.2
42. Submitting
Involuntary
Disenrollment
Requests
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
a. The enrollee’s behavior is disruptive,
unruly, abusive or uncooperative to the
extent that enrollment in the health plan
seriously impairs the organization’s
ability to furnish services to either the
enrollee or other enrollees.
b. This section does not apply to enrollees
with mental health diagnoses if the
enrollee’s behavior is attributable to the
mental illness.
c. An involuntary disenrollment request
related to enrollee behavior must include
documentation that the health plan:
i. Provided the enrollee at least one oral
warning and at least one written
warning of the full implications of the
enrollee’s actions.
ii. Attempted to educate the enrollee
regarding rights and responsibilities.
iii. Offered assistance through case
management that would enable the
enrollee to comply.
iv. Determined that the enrollee’s
behavior is not related to the
enrollee’s medical or behavioral
condition.
The health plan promptly submits
disenrollment requests to BMHC.
In no event will the health plan submit a
Yes
No
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_III_F2_07_11
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