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

Standard III: Eligibility, Enrollment, and Disenrollment
CONTRACT
SECTION
46. Reasons
Disenrollment
Cannot be
Requested
42 CFR 438.56(b)(2)
42 CFR 438.56(c)(5)
CC-III.C.4.d
47. Notifying the
Enrollee of
Disenrollment
CC-III.C.4.e
48. REFORM:
Involuntary
Disenrollment
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan cannot request disenrollment
of an enrollee due to:
a. Health diagnosis.
b. Adverse changes in an enrollee’s
health status.
c. Utilization of medical services.
d. Diminished mental capacity.
e. Pre-existing medical conditions.
f. Uncooperative or disruptive behavior
resulting from the enrollee’s special
needs.
g. Attempt to exercise rights under the
health plan’s grievance system.
h. Request of one PCP to have an
enrollee assigned to a different
provider out of the health plan.
When the health plan requests an involuntary
disenrollment, the plan notifies the enrollee in
writing that the health plan is requesting
disenrollment, the reason for the request, and
an explanation that the health plan is
requesting that the enrollee be disenrolled in
the next contract month, or earlier if
necessary. Until the enrollee is disenrolled, the
health plan is responsible for the provision of
services to that enrollee.
The Reform health plan submits involuntary
disenrollment requests for the following
reasons to the Agency’s choice
counselor/enrollment broker as specified in
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
g. Yes
No
h. Yes
No
Yes
No
a. Yes
No
N/A
b. Yes
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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