Definitions, Confidentiality, Florida KidCare Dispute Review Process, Florida KidCare Grievance Committee, Florida KidCare Grievance Procedures

 

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO: RULE TITLE
59G-14.001: Definitions
59G-14.002: Confidentiality
59G-14.004: Florida KidCare Dispute Review Process
59G-14.005: Florida KidCare Grievance Committee
59G-14.006: Florida KidCare Grievance Procedures

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 33 No. 41, October 12, 2007 issue of the Florida Administrative Weekly.

These changes are in response to comments received from the Joint Administrative Procedures Committee (JAPC) and from the Florida Healthy Kids Corporation.

59G-14.001(2) Complaint or dispute – We inserted timeframe language so that the definition now reads, “‘Complaint’ or ‘dispute’ is a verbal or written expression of dissatisfaction, regarding an eligibility or enrollment decision received within 90 calendar days of the date of the letter indicating the suspension or termination of a child’s enrollment.”

59G-14.001(3) Complainant or grievant – We revised the first two sentences to read, “‘Complainant’ or ‘grievant’ is a parent, legal guardian, an authorized representative of the parent or legal guardian or a child whose disability of nonage has been removed who submits a complaint or grievance on behalf of an applicant, enrollee or former enrollee of the Florida Kidcare Program. If a parent, legal guardian or a child whose disability of nonage has been removed appoints a representative . . .”

59G-14.001(5) Enrollee – We added the following definition of enrollee, “‘Enrollee’ means a child who has been determined eligible for and is receiving coverage under Sections 409.810-.820, F.S.” We renumbered the previous 59G-14.001(5) Florida Kidcare Partners through 59G-12.001(12) Third Party Administrator to subsections 59G-14.001(6) through 59G-14.001(13), F.A.C.

59G-14.001(11) Health Services, formerly 59G-14.001(10) – We added dental services so the definition now reads, “‘Health Services’ means the medical and dental benefits provided by an individual’s health care coverage (e.g., hospital services, physician services, prescription drugs and laboratory services).”

59G-14.001(13) Third Party Administrator, formerly 59G-14.001(12) – We deleted the wording specifying the administrative services performed by the third party administrator and inserted the Florida Statute provision, 624.91(5)(b)(8), F.S., which authorizes Florida Healthy Kids Corporation to assign KidCare responsibilities to a contracted third party administrator. The definition now reads, “‘Third Party Administrator’ is the entity contracted by Florida Healthy Kids Corporation that is responsible for administrative services for the Florida Kidcare Program, Title XXI Programs as authorized by 624.91(5)(b)(8), F.S.”

59G-14.002 Confidentiality – We revised the rule to read, “The Florida Kidcare Dispute Review Process and the Florida Kidcare Grievance Review Process shall conform to s. 409.821, F.S., Health Insurance Portability and Accountability Act of 1996, and Title 42, Part 431, Subpart F of the Code of Federal Regulations with respect to confidentiality of information.”

59G-14.004(1), (2) Florida Kidcare Dispute Review Process – We reworded the paragraphs to read: “(1) The Florida Kidcare Dispute Review Process is the means by which the Florida Kidcare Program provides a comprehensive review of complaints relating to eligibility and enrollment. During the review process, complaints or disputes are investigated and resolved for eligibility or enrollment matters regarding:

(a) Denial of eligibility;

(b) Failure to make a timely determination of eligibility; and

(c) Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.

(2) Health service matter disputes regarding a delay, denial, reduction, suspension, or termination of health services and a failure to approve, furnish, or provide payment for health services in a timely manner are reviewed and resolved through a process developed independently for each Florida Kidcare program entity as referenced in 59G-14.007, F.A.C.”

59G-14.004(3) – We added language to clarify the role of the third party administrator during the Florida KidCare Informal Dispute Review Process. The rule now reads, “The Third Party Administrator for the Florida Healthy Kids Corporation determines eligibility and processes informal disputes received during “Level One” of the dispute review process for the non-Medicaid components of the Florida Kidcare Program. The Florida Healthy Kids Corporation is responsible for reviewing the formal eligibility and enrollment disputes for the Florida Kidcare Program. The Florida Healthy Kids Corporation Resolution Staff is responsible for conducting the Florida Kidcare Dispute Review Process.”

59G-14.004(4)(b) – We revised the first sentence to read, “If the Florida Kidcare customer service representative determines that a dispute cannot be resolved through a telephone conversation, the Florida Kidcare customer service representative shall request the complainant forward documentation concerning the dispute to the Florida Healthy Kids Corporation office within 90 calendar days of the date of the letter received indicating denial, suspension or termination of enrollment.”

59G-14.005(1) – We revised the rule to read, “The Florida Kidcare Grievance Committee shall review and resolve grievances related to the Florida Kidcare Program when all four levels of resolution through the Florida Kidcare Dispute Review Process have been completed. Grievances involving more than one Florida Kidcare Program will also be addressed by this committee. Disputes involving more than one Florida Kidcare Program shall be immediately referred to the Kidcare Grievance Committee. Grievances heard by the Florida Kidcare Grievance Committee shall include eligibility and enrollment matters relating to Florida Healthy Kids, MediKids or the Children’s Medical Services Network. The following provisions apply to the Florida Kidcare Grievance Committee:”

59G-14.006(1) – We revised the first sentence to read, “If the grievant is dissatisfied with the action taken by the Florida Healthy Kids Board of Directors during the Level Four process of the Florida Kidcare Dispute Review process, the grievant can submit a written request for the Florida Kidcare Grievance Committee to review the grievance.”

59G-14.006 (3) – In the third sentence, we added the timeframe for a response. The sentence now reads, “If the initial eligibility or enrollment decision is correct and the Florida Healthy Kids Corporation followed the dispute review process outlined in this rule, the complainant will be notified in writing within five (5) calendar days of the Agency receiving the completed and executed forms referenced in 59G-14.006 (2) of this rule, that the decision determined during the Florida Kidcare Dispute Review Process shall remain unchanged.”