The purpose of the amendment to Rule 59G-14.001, Florida Administrative Code (F.A.C.), is to update the definitions, incorporate the requirements of Rules 59G-14.002-14.007, F.A.C., as appropriate, and revise the rule title.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-14.001Definitions

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-14.001, Florida Administrative Code (F.A.C.), is to update the definitions, incorporate the requirements of Rules 59G-14.002-14.007, F.A.C., as appropriate, and revise the rule title.

SUMMARY: The incorporated policy will describe the dispute resolution process, along with requirements to participate in the process. The amendment also revises the title of the rule to Florida Kidcare Dispute Review and Grievance Process.

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: 409.818 FS.

LAW IMPLEMENTED: 409.818 FS.

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

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

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, 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: Angela Wiggins. 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: Angela Wiggins, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Official comments to be entered into the rule record will be received from the date of this notice until May 12, 2016. Comments may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-14.001 Florida Kidcare Dispute Review and Grievance Process Definitions.

(1) Purpose. The Florida Kidcare Dispute Review and Grievance Process (Process) is a comprehensive review of disputes relating to eligibility and enrollment for the Title XXI, Children’s Health Insurance Program (CHIP), conducted in accordance with Title 42, Code of Federal Regulations (CFR), sections 457.1130-457.1180.

(2) Definitions. The following definitions are applicable to this rule and the Title XXI, Florida Kidcare Programs (Children’s Medical Services Network, Florida Healthy Kids and MediKids) and to all sections of Florida Kidcare Grievance Procedures, Chapter 59G-14, F.A.C. These definitions do not apply to any dispute or grievance processes issues relating to the Florida Medicaid program for Children eligibility, enrollment or renewal activities. For Medicaid eligibility and enrollment complaint or grievance issues, families must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rule 65-2.045, F.A.C.

(a) Adverse action notice – Letter regarding a premium increase, denial of eligibility, suspension or termination of enrollment, or disenrollment for failure to pay the premium.

(1) “Applicant” refers to a parent or guardian of a child or a child whose disability of nonage has been removed under Chapter 743, F.S., who applies for eligibility under Sections 409.810-.820, F.S. (Florida Kidcare Act).

(2) “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.

(b) (3) “Complainant – An individual listed on the enrollee’s Florida Kidcare account as ” or “grievant” is a parent, caretaker, or an emancipated minor who submits a dispute or grievance. 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 to discuss the complaint or grievance on their behalf, they must complete and sign an Appointment of Representation Form, AHCA Med-Serv Form 017, August 2007, one page, and the Authorization for the Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018, August 2007, two pages, which are incorporated by reference. These forms name the representative and give the representative access to medical records in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

(c) Dispute – Written request to review an eligibility or enrollment decision received within 90 calendar days of the date of an adverse action notice.

(d) (4) “Dispute Review File – Documents collected by the Florida Healthy Kids Corporation or provided by the family during the Resolution Hearing” is the complainant’s opportunity to be heard by the Florida Kidcare Dispute Review Panel during the third level of the Florida Kidcare Formal dDispute rReview pProcess. If requested, a professionally transcribed hearing is scheduled between the complainant and the Florida Kidcare Dispute Review Panel in the complainant’s county of residence.

(e)(5) “Enrollee – ” means a Cchild who has been determined eligible for and is receiving CHIP coverage under the Florida Kidcare Act Sections 409.810-.820, F.S.

(f) Florida Healthy Kids Corporation (Corporation) – Designated eligibility processor for the CHIP program. The Corporation is also responsible for conducting the dispute review process and preparing all written dispute review responses.

(g) Grievance - Written request to review an eligibility or enrollment decision after the dispute review process has been completed. 

(6) “Florida Kidcare Partners” includes the Agency for Health Care Administration (MediKids), the Department of Children and Family Services (Medicaid for Children), the Department of Health (Children’s Medical Services Network), and the Florida Healthy Kids Corporation (Healthy Kids). Families with children receiving coverage under the Medicaid for Children Program must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rule 65-2.045, F.A.C.

(7) “Florida Kidcare Formal Dispute Review Process” is a comprehensive review of an eligibility or enrollment complaint. The formal dispute review process begins when a written request to resolve a dispute is received by the Florida Healthy Kids Corporation’s Resolution Coordinator. The entire dispute review process is conducted by the Florida Healthy Kids Corporation, the eligibility processor for the Florida Kidcare, Title XXI Programs.

(8) “Florida Kidcare Informal Dispute Review Process” is the initial contact in writing or telephone to the Florida Healthy Kids Corporation, expressing dissatisfaction with a disputable application or enrollment action.

(9) “Florida Kidcare Grievance Committee” or “committee” is the entity responsible for hearing and resolving grievances related to the Florida Kidcare Program when all avenues of resolutions through the Florida Kidcare Dispute Review Process have been exhausted. For Medicaid eligibility and enrollment grievance issues, families must request a Medicaid Fair Hearing by contacting the Department of Children and Family Services (DCF) as referenced in Rule 65-2.045, F.A.C.

(10) “Grievance” means a formal written complaint initiated to challenge an eligibility or enrollment decision only after all other forms of resolution have been exhausted through the Florida Kidcare Formal Dispute Review Process.

(11) “Health Services  ” means the medical, behavioral and dental benefits provided by an individual’s health or dental coverage (e.g., hospital services, physician services, prescription drugs and laboratory services).

(12) “Resolution Coordinator” is the person responsible for supervising the dispute review process and preparing a written response to the complainant explaining the Florida Healthy Kids Corporation or Florida Kidcare Dispute Review Process decision regarding eligibility or enrollment.

(13) “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 Sections 624.91(5)(b)8., F.S.

(3) Dispute Review Process.

(a) The dispute review process is conducted in accordance with time frames specified in 42 CFR 457.1160.

(b) The dispute review process begins when the Corporation receives a dispute from a complainant. For disputes received within ten calendar days of an adverse action notice, the Corporation will take the following actions when requested by the complainant:

1. Continue or reinstate health coverage retroactive to the first day of the month in which the request for continuation was received.

2. Restore the former premium amount. All premium payments must be paid in a timely manner to maintain coverage during the continuation period.

(c) The Corporation must explain the complainant’s liability to repay all premiums and cost of benefits received if the original adverse action decision is upheld.

(d) The Corporation must comply with the following time frames:

1. Send written acknowledgement to the complainant, within three calendar days of receipt of the dispute.

2. Render a written decision within 15 calendar days of receipt of the dispute.

(e) The Corporation may request additional information from the complainant and extend the dispute review period for up to 30 calendar days. Additional information requested by the Corporation must be provided within ten calendar days; if requested information is not provided, the Corporation will render a decision based on the available information. 

(f) The complainant will be notified of the decision by the Corporation.

(g) The complainant may appeal the dispute review process decision to the Corporation’s Chief Executive Officer (Officer) or designee. The Officer will notify the complainant of the decision in writing within ten calendar days of the complainant’s dispute review decision appeal request, and provide information regarding additional appeal rights as described in paragraph (h). 

(h) The complainant may appeal the Officer’s decision by submitting a grievance request through the Corporation to the Agency for Health Care Administration (AHCA), within ten calendar days of the Officer’s decision. The Corporation must forward the grievance request and the dispute review file to AHCA within five calendar days of receipt of the grievance request.

(4) Grievance Process.

(a) The Agency for Health Care Administration will send a letter to the complainant within five calendar days of receiving the grievance request:

1. Acknowledging receipt of the grievance.

2. Requesting additional information, if needed.

3. Instructing how a complainant may request a copy of the dispute review file and appoint a representative.

(b) Complainants must submit any requested additional information to AHCA within 10 calendar days.

(c) The Agency for Health Care Administration will render its final decision in writing based on the available information within 30 calendar days of receiving the grievance request.

(d) MediKids, Healthy Kids, and Title XXI Children’s Medical Services Managed Care Plan are bound by AHCA’s final decision.

Rulemaking Authority 409.818 FS. Law Implemented 409.818 FS. History–New 2-27-08,Amended________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Angela Wiggins

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

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: April 12, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: February 10, 2016