The purpose of the amendment to Rule 59G-8.600, Florida Administrative Code (F.A.C.), is to clarify the requirements for good cause disenrollment, by enrollees, from Statewide Medicaid Managed Care (SMMC) plans. The amendment also revises the rule ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-8.600Good Cause for Disenrollment from Health Plans

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-8.600, Florida Administrative Code (F.A.C.), is to clarify the requirements for good cause disenrollment, by enrollees, from Statewide Medicaid Managed Care (SMMC) plans. The amendment also revises the rule title to Good Cause for Disenrollment from Managed Care Plans.

SUMMARY: The amendment specifies the reasons an enrollee may request good cause disenrollment from a managed care plan and revises the rule title.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.961 FS.

LAW IMPLEMENTED: 409.965, 409.969 FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: February 26, 2016, 10:00 a.m. – 11:00 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room A, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Devona Pickle. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Devona Pickle, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-8.600 Good Cause for Disenrollment from Managed Care Health Plans.

(1) Purpose. A Florida Medicaid recipient (herein referred to as an enrollee) who is required to enroll in the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) or Long-term Care (LTC) program, may request to change managed care plans for good cause at any time. Such request must be submitted by telephone to the Agency for Health Care Administration (AHCA) or its enrollment broker. Enrollees required to enroll in SMMC programs should not interpret this rule as an exemption from participation in Florida Medicaid’s SMMC program. This rule only applies to the process and reasons for which managed care enrollees may change plans. Recipients subject to the 12-month enrollment period may request disenrollment from the health plan for cause at any time during their no-change period. The no change period is defined as the period of time during which a recipient cannot change plans without a good cause reason in accordance with 42 CFR 438.56(c). Recipients making such requests must submit the request to the call center representative for a determination.

(2) Definitions. Active relationship - when an enrollee has received services from a service provider within the six months preceding a disenrollment request.

(3)(2) Good Cause Reasons. The following reasons, as confirmed by AHCA, constitute good cause for disenrollment from a managed care the health plan:

(a) The enrollee does not live in a region where the managed care plan is authorized to provide services, as indicated in the managed care plan’s contract with AHCA recipient moves out of the county, or the recipient’s address is incorrect and the recipient does not live in a county, where the health plan is authorized to provide services.

(b) The enrollee recipient is excluded from enrollment in a managed care plan, pursuant to sections 409.965, 409.972, and 409.979, Florida Statutes (F.S.).

(c) The managed care plan has committed a A substantiated marketing violation directly impacting the enrollee occurred with the individual recipient that is substantiated by the Agency for Health Care Administration, Bureau of Managed Health Care. The recipient must submit the allegation in writing to the Bureau of Managed Care, 2727 Mahan Drive, M.S. 26, Tallahassee, FL 32308.

(d) The enrollee recipient is prevented from participating in the development of his or her treatment plan or plan of care.

(e) The enrollee recipient has an active relationship with a service health care provider that is not in on the managed care health plan’s network, but is in the network of another managed care health plan ; or the health care provider with whom the recipient has an active relationship is no longer with the health plan.

(f) The recipient is ineligible for enrollment in the health plan.

(g) The health plan no longer participates in the county in which the recipient resides.

(f) The state has imposed intermediate sanctions upon the managed care plan, as specified in Title 42, Code of Federal Regulations (CFR), section 438.702(a)(3).

(g)(h) The enrollee recipient needs related services to be performed concurrently (for example, a cesarean section and tubal ligation), but not all related services are available within the managed care health plan’s network; or the enrollee’s recipient’s primary care provider (PCP) has determined that receiving the services separately would subject the enrollee recipient to unnecessary risk.

(h)(i) The managed care health plan does not, because of moral or religious objections, cover the service the enrollee recipient seeks.

(i) The enrollee missed open enrollment due to a temporary loss of eligibility.

(j) Other reasons, per 42 CFR 438.56(d)(2) and section 409.969(2), F.S.

(k)(j) Poor quality of care.

(l)(k) Lack of access to services covered under the SMMC contract, including lack of access to medically-necessary specialty services.

(m)(l) The managed care health plan makes inordinate or inappropriate changes of the recipient’s primary care provider (PCP).

(n)(m) An unreasonable delay or denial of service.

(o)(n) Service access impairments due to significant changes in the geographic location of services.

(p)(o) There is a lack of access to health plan providers experienced in dealing with the recipient’s health care needs.

(q)(p) Fraudulent enrollment.

(r)(q) The enrollee, recipient, who meets the eligibility requirements for a specialty plan, but is although otherwise locked in, requests enrollment in a specialty plan and meets the eligibility requirements for the specialty plan.

(s)(r) The enrollee recipient received a notice from his or her managed care plan of a reduction in required benefits following an amendment to the managed care at the end of the plan’s SMMC annual contract year (for the next year).

(4)(3) The Agency for Health Care Administration will process all disenrollments from the managed care plan. The Agency for Health Care Administration, or its designee, will make final determinations about granting disenrollment requests and will notify the enrollee by surface mail of any disenrollment decision. Enrollees dissatisfied with the determination may request a Florida Medicaid fair hearing, pursuant to 42 CFR Part 431, Subpart E. The Agency’s vendors shall mail a Disenrollment Denial Letter, AHCA/HSD Form #1, Eng., January 2009; Spanish version, AHCA/HSD Form #1Sp., January 2009; or Creole version, AHCA/HSD, Form #1C., January 2009, incorporated by reference, to recipients whose requests to disenroll from plans during the no change period are denied.

Rulemaking Authority 409.961 409.91211, 409.9122, 409.919 FS. Law Implemented, 409.965, 409.969 409.912, 409.91211, 409.9122, FS. History–New 2-26-09, Amended,__________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Devona Pickle

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: January 20, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: September 17, 2015