6M-9.400. Early Learning Coalitition Anti-Fraud Plans

(1) Definitions. As used in this rule:

(a) “Recipient” is the parent or legal guardian whose child was determined eligible for School Readiness or Voluntary Prekindergarten Education Program benefits.

(b) “Fraud” is an intentional deception, omission, or misrepresentation made by a person with knowledge that the deception, omission, or misrepresentation may result in unauthorized benefit to that person or another person, or any aiding and abetting of the commission of such an act. The term includes any act that constitutes fraud under applicable federal or state law.

(2) Anti-fraud plan approval. Each early learning coalition (coalition) shall adopt an anti-fraud plan addressing the detection and prevention of overpayments, abuse, and fraud relating to the provision of and payment for School Readiness program and Voluntary Prekindergarten Education Program services and submit the plan to the office for approval. The anti-fraud plan must be approved by the coalition board prior to submission to the Office of Early Learning. The plan must be sent to the Office of Early Learning’s Office of Inspector General no later than June 30 of each year. Submission may be electronic or through the mail. The Office of Early Learning will process the plan no later than September 1 of each year and shall notify the coalition in writing of approval or disapproval and the reasons for disapproval. If disapproved, a corrected plan shall be submitted no later than November 1 of each year.

(3) Criteria for approval of anti-fraud plan. Each coalition’s anti-fraud plan shall include:

(a) A description or chart outlining the organizational structure of the plan’s personnel who are responsible for the investigation and reporting of possible overpayment, abuse, or fraud. This shall include the name and contact information of the primary coalition position responsible for implementing the early learning coalition’s anti-fraud activities.

(b) A description of the plan’s procedures for detecting and investigating possible acts of fraud, abuse, or overpayment. This shall include a review of data quality reports generated from the Office of Early Learning, documented verification of child care referrals from other organizations, a process for electronic monthly reporting to the Office of Early Learning the recipients and providers terminated for fraud, and a description of any fraud hotlines in place and how this information is shared with parents, providers, employees and the public.

(c) A description of the plan’s procedures for the mandatory reporting of possible abuse or fraud, including the possible overpayment associated with the abuse or fraud, to the Office of Early Learning’s Office of Inspector General. This shall include the name and contact information of the coalition position serving as the coalition administrator for the Office of Early Learning Fraud Referral System.

(d) A description of the plan’s program and procedures for education and training personnel on how to detect and prevent fraud, abuse, and overpayment including an annual self-assessment of the coalition’s internal controls, policies and procedures.

(e) A description of the plan’s procedures, including the appropriate due process provisions for suspending or terminating from the School Readiness program or the Voluntary Prekindergarten Education Program a recipient who the coalition concludes has committed fraud. Due process provisions must include all elements set forth in subsection (4) below.

(4) Due process requirements for recipients. The early learning coalition anti-fraud plan shall include the following elements establishing due process:

(a) A clear policy of the right of the recipient to appeal suspension or termination of benefits based on information that leads the coalition to conclude that School Readiness or Voluntary Prekindergarten Education program benefits have been obtained or used fraudulently.

(b) The coalition shall provide written advance notice of the intended action to suspend or terminate benefits to the recipient to be affected and it must clearly advise of the allegations, the basis of the allegations, the intended action and the date the action is to be imposed. The coalition shall send the written advance notice at least fourteen (14) calendar days before the intended action. The written advance notice should be translated into the recipient’s native language if the coalition’s other communications with the recipient have been translated. The written advance notice shall include following:

1. The procedure for the recipient to follow to attempt to appeal the decision.

2. A statement, in bold print, that the failure to file a timely appeal waives the right to an appeal.

3. Notice of the potential for repayment of improper benefits if the conclusion of fraud is upheld, including any benefits received after the receipt of the written advance notice.

4. The procedure for the recipient to obtain a copy of his or her file.

5. The amount of overpayment to be recovered, if applicable.

6. The length of time for which the recipient’s benefits are suspended or the date of the termination of benefits, if applicable. This length of time shall be proportionate to the alleged offense committed, consistent with suspensions or terminations issued to other recipients who allegedly committed comparable offenses, and may also consider prior offenses, as appropriate.

(c) A suspension or termination shall not be applied against recipients with a valid at-risk referral.

(d) If the recipient believes that the conclusion of fraud was made in error, the recipient should first seek to resolve the matter by contacting the coalition and providing the necessary documentation to resolve the issue. The executive director of the coalition shall not be involved in the pre-appeal resolution of the issue.

(e) If the recipient believes that the issue was not resolved by the coalition, the recipient may file a formal written appeal for review by the executive director of the coalition, using the following procedure:

1. Submit a written appeal to the executive director or other executive staff person as designated by the coalition board. The appeal must fully describe the nature of the error the recipient believes has been made and shall contain any documentation which supports the recipient’s claim.

2. The appeal shall be postmarked or emailed before the date of the intended action. The recipient who fails to file a timely appeal waives the right of appeal.

3. If the recipient files a timely appeal, he or she will not be suspended or terminated from the program until the written decision of the executive director or the original date of the intended action, whichever is later.

4. The executive director of the coalition or other executive staff person designated by the coalition board must respond to the recipient, in writing, within thirty (30) days of receiving the appeal with a decision as to whether the suspension or termination will be upheld or modified.

5. The recipient who wishes to appeal the decision of the executive director of the coalition or other executive staff person designated by the coalition board may request further review by an appeals committee in accordance with paragraph (e) of this rule. The request for further review by an appeals committee must be submitted to the coalition in writing within ten (10) calendar days of the date of the executive director or other executive staff person designated by the coalition board’s written response to the recipient’s formal written appeal.

(f) The recipient shall be given the opportunity to defend his or her position in an orderly proceeding of the appeals committee. When the meeting of the appeals committee is scheduled, the recipient shall be notified of the date of the appeals committee, informed that it is a public meeting, and informed that any information presented may be used by other state agencies.

1. The appeals committee shall be selected by the Chairman of the Board of the coalition and a chair of the appeals committee shall be named.

2. The appeals committee shall be convened within forty-five (45) calendar days of receipt of the recipient’s request for an appeal.

3. The recipient shall be provided up to thirty (30) minutes to present their position and any information they wish the appeals committee to consider.

4. The coalition staff, excluding the executive director or other executive staff person designated by the coalition board, shall be available to provide any information requested by the committee.

5. The appeals committee will consider all statements, review all documents and may request any additional evidence or information from the parties if an appeals committee member believes it is necessary and relevant to the decision making. The required final determination letter will be tolled for the length of time given to provide the additional information.

6. The appeals committee shall selected or appoint a member of the coalition, excluding the executive director the coalition or other executive staff person designated by the coalition board, to memorialize the events of the appeals committee proceeding and the final determination including the basis for the decision.

7. The appellant shall be notified in writing of the appeals committee’s determination within ten (10) days of the date of the meeting.

8. The determination of the appeals committee shall be final.

(5) The due process procedures for providers will be provided for in the contract between the coalition and the provider, pursuant to Rule 6M-4.610, F.A.C.

Rulemaking Authority 1001.213(2), 1002.91(4), (8) FS. Law Implemented 1002.91(4), (8) FS. History–New 3-1-15.