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

Standard IV: Enrollee Services & Enrollee Rights
CONTRACT
SECTION
22. Choice of PCP
CC-IV.A.5.a
23. Group or Single
PCP
CC-IV.A.5.a
24. Assigning a PCP
CC-IV.A.5.b
25. Changing PCPs
CC-IV.A.5.c
26. Reinstated
Enrollee PCP
Assignment
CC-IV.A.5.d
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
The health plan offers each enrollee a
choice of PCPs.
Yes
No
Each enrollee has a single or group PCP. Yes
No
The health plan assigns a PCP to those
enrollees who did not choose a PCP at
the time of health plan selection.
Considerations include: the enrollee’s
last PCP, closest PCP to the enrollee’s
ZIP code, keeping the family together,
and age.
The health plan permits enrollees to
request to change PCPs at any time. If
the request is not received by the
established monthly cut-off date, the
PCP change will be effective the first
day of the next month.
The health plan assigns all enrollees that
are reinstated after a temporary loss of
eligibility to the PCP treating them prior
to the loss of eligibility unless the
enrollee requests another PCP, the PCP
no longer participates or is at capacity,
or the enrollee changed geographic
areas.
Yes
No
Yes
No
Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_IV_F2_07_11
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