Section 409.818(3)(e), F.S., directs the Agency for Health Care Administration to establish a mechanism for investigating and resolving complaints and grievances for the Florida KidCare Program. The purpose of the proposed rule is to establish the ...

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO: RULE TITLE
59G-14.001: Florida KidCare Definitions
59G-14.002: Florida KidCare Grievance Process
PURPOSE AND EFFECT: Section 409.818(3)(e), F.S., directs the Agency for Health Care Administration to establish a mechanism for investigating and resolving complaints and grievances for the Florida KidCare Program. The purpose of the proposed rule is to establish the Agency’s Florida KidCare grievance process in rule.
This Notice of Rule Development replaces the Notice of Rule Development that was published in the Vol. 32, No. 40, October 6, 2006, issue of the Florida Administrative Weekly. In that Notice we erroneously advertised the rule development workshop date as Monday, October 23, 2007 instead of October 23, 2006. We are publishing a second Notice of Rule Development to advertise another workshop.
SUBJECT AREA TO BE ADDRESSED: Florida KidCare.
SPECIFIC AUTHORITY: 409.818 FS.
LAW IMPLEMENTED: 409.818 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: Monday, November 20, 2006, 2:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Blvd., Bldg. 3, Conference Room D, Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Angela Wiggins, Medicaid Services, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, [phone]

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-14.001 Florida KidCare Definitions.

The following definitions are applicable to all sections of Chapter 59G-14, F.A.C. These definitions do not apply to any Medicaid program rules other than those in Chapter 59G-14, F.A.C.

(1) “Complaint” may be either written or verbal. A complaint is an expression of dissatisfaction.

(2) “Problem” may be either written or verbal. It is a question offered for consideration, discussion or solution.

(3) “Grievance” is a formal complaint process initiated only after all other forms of resolution have been exhausted and the complainant has not obtained relief. A grievance must be submitted in writing and must be signed by the complainant.

(4) “Florida KidCare Grievance Committee” or “Committee” is the entity responsible for hearing and resolving complaints and grievances related to the Florida KidCare program as delineated in these procedures.

(5) “Florida KidCare Partners” include the Agency for Health Care Administration, the Department of Children and Families, the Department of Health, and the Florida Healthy Kids Corporation.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New_________.

 

59G-14.002 Florida KidCare Grievance Process.

(1) The following provisions apply to the Florida KidCare Grievance Committee:

(a) The Florida KidCare Grievance Committee consists of one representative from each of the following Florida KidCare partners, appointed by their respective organization’s agency head:

1. Agency for Health Care Administration.

2. Department of Children and Families.

3. Department of Health.

4. Florida Healthy Kids Corporation.

5. A family representative nominated by the KidCare Partners.

(b) The Agency for Health Care Administration’s representative will serve as the committee chairperson. The committee members will elect a co-chair, who will serve as the chairperson in the absence of the Agency’s representative.

(c) A quorum of at least three appointed members, or their designated representative (proxy), is required to make decisions on grievance cases the committee hears. Committee members or their designated representative must be present at the meeting to review documentation.

(d) Staff from the Agency for Health Care Administration will serve as committee staff, prepare committee minutes, and prepare communications to affected parties on behalf of the committee.

(e) Unless otherwise specified, committee meetings will be held in Tallahassee at the Agency for Health Care Administration’s Headquarters offices.

(2) Initial complaints and problems will be routed to the appropriate KidCare partner for resolution. All initial complaints and problems must be answered within a reasonable length of time, not to exceed ten (10) business days from initial filing by the complainant, unless the complainant and affected KidCare partner mutually agree to extend the time. Emergency issues will be addressed within twenty-four (24) hours. Only when the affected KidCare partner has failed to provide relief may the issue be elevated to the form of a formal grievance for review by the committee.

(3) Florida KidCare Grievance Procedures.

(a) A formal grievance must be submitted to the committee in writing and signed by the complainant. The complainant may submit the request on the KidCare Formal Grievance Request Form, AHCA Med-Serv Form 009, Sept. 06, which is incorporated by reference. In the event that a complainant is unable to submit a request in writing, assistance will be provided and a dictation of the grievance will be accepted. All formal grievances must be sent to: Florida KidCare Grievance Committee, Bureau of Medicaid Services, 2727 Mahan Drive, MS 20, Tallahassee, Florida 32308.

(b) In the event a formal grievance is submitted by someone other than the custodial parent or legal guardian, no confidential information will be released to the complainant. The grievance will be investigated and notification will be sent to the custodial parent or legal guardian.

(c) Upon receipt of a formal grievance, the Agency for Health Care Administration staff will send a letter of acknowledgement to the complainant informing them of the process, established time frames, and any additional information needed to proceed. If additional information is necessary, the KidCare Formal Grievance Request Form, AHCA Med-Serv Form 009, will be sent to the complainant for completion.

(d) Agency for Health Care Administration staff will review the grievance and determine if the affected KidCare partner used appropriate measures in handling the previous problem and complaint phases of resolution. When necessary, the appropriate KidCare partner will be contacted and asked to provide information relevant to the case. If the affected KidCare partner used appropriate action in handling the grievance, the complainant will be notified in writing.

(e) If it is determined that further remedy is warranted, the committee will be required to hear the grievance. The committee shall hear the grievance at its next regularly scheduled meeting.

(f) The committee shall meet the second Monday of each month. The committee will not meet if there are no pending grievances. Additional meetings to resolve a grievance will be scheduled, as needed. If further documentation is necessary for the committee to reach a decision, extensions of thirty (30) days will be granted. The complainant will be notified in writing of each extension. When a decision is rendered by the committee, the complainant will be notified in writing within thirty (30) calendar days.

(g) The committee members will review all pertinent information. When committee members have assessed the grievance information presented, the committee members will verbally vote to render a decision. The committee’s decision will be based on a majority vote. The decision of the committee is final and all KidCare partners will abide by such decision.

(h) The KidCare grievance process will comply with Section 409.821, Florida Statutes, with regard to confidentiality of records for the Florida KidCare program.

(4) The Florida KidCare Grievance Committee will hear grievances for which no other vehicle of remedy exists. Grievances heard by the committee shall include eligibility issues relating to Healthy Kids, MediKids or the Children’s Medical Services Network. Grievances involving more than one KidCare program will be addressed by this committee. Complaints, problems or grievances associated with the following issues will not be heard by the Florida KidCare Grievance Committee:

(a) Quality of care. When contacted with quality of care complaints, problems or grievances, the Florida KidCare partners will make appropriate referrals to existing mechanisms to address these issues.

(b) Benefits disputes. Each Florida KidCare partner is responsible for resolving disputes about benefits relating to its own program.

(c) Medicaid eligibility issues. All decisions made by the Department of Children and Families with respect to Medicaid eligibility are final and may not be appealed beyond the Department’s own fair hearing process.

Specific Authority 409.818 FS. Law Implemented 409.818 FS. History–New_________.