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

Standard IV: Enrollee Services & Enrollee Rights
CC- IV.A.9.d
CONTRACT
SECTION
42. Enrollee
Representative
CC- IV.A.10
43. Toll-free Help Line
CC- IV.A.11.a
44. Hernandez
Ombudsman (HO)
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
hospitalization or nursing home
placement (i.e., hospitalization of spouse
or caregiver or increased impairment of
an enrollee living alone who suddenly
cannot manage basic needs without
immediate help, hospitalization or
nursing home placement).
The enrollee’s guardian, next of kin or
legally authorized responsible person is
permitted to act on the enrollee’s behalf
in matters relating to the enrollee’s
enrollment, plan of care, and/or
provision of services, if the enrollee:
a. Was adjudicated incompetent in
accordance with the law.
b. Is found by the provider to be
medically incapable of
understanding his or her rights.
c. Exhibits a significant
communication barrier.
The health plan operates a toll-free
telephone help line to respond to all
areas of enrollee inquiry.
If the health plan has authorization
requirements for prescribed drug services
and is subject to the Hernancez
Settlement Agreement (HSA), the health
plan allows the telephone help line staff
to act as HO, so long as the health plan
maintains the HO log.
a. Yes
No
b. Yes
No
c. Yes
No
Yes
No
Yes
No
N/A
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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