To update the clinical eligibility screening process for the CMS Managed Care Plan.

 

DEPARTMENT OF HEALTH

Division of Children’s Medical Services

RULE NO.:RULE TITLE:

64C-2.002Eligibility for CMS Network Services

PURPOSE AND EFFECT: To update the clinical eligibility screening process for the CMS Managed Care Plan.

SUMMARY: The proposed rule will add additional options for families and physicians to utilize a medical review panel to determine clinical eligibility. The proposed rule also clarifies that families may request a re-screening to determine clinical eligibility if clinical eligibility was not previously established.

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: Based on the SERC checklist, this rulemaking will not have an adverse impact on regulatory costs in excess of $1 million within five years as established in s.120.541(2)(a), F.S.

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: 391.026(18) FS.

LAW IMPLEMENTED: 391.026(3), 391.029 FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN THE FAR.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Kelli Stannard, 4052 Bald Cypress Way, Bin B-01, Tallahassee, Florida, 32399, telephone: [phone], [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

64C-2.002 Clinical Eligibility for the CMS Managed Care Plan.

(1) A child’s Cclinical eligibility for the CMS Managed Care Plan may be established by an authorized representative of the Department through completion of the CMS Clinical Eligibility Screening Form, DH8000-CMS (12/2015), incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-06270.

(2) Clinical eligibility for the CMS Managed Care Plan may be established by Children with a diagnosis of one or more of the health conditions listed on the CMS Clinical Eligibility Attestation form, as attested to by a physician, are clinically eligible for enrollment in the CMS Managed Care Plan. The CMS Clinical Eligibility Attestation, Form DH8001-CMS (05/2016) (12/2015) is incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX http://www.flrules.org/Gateway/reference.asp?No=Ref-06271.

(3) If clinical eligibility is not established after the evaluations described in subsections (1) and (2), re-screening may be requested by contacting the CMS Plan office or at www.cmsplan.floridahealth.gov.   

(4) Application may be made for children with a diagnosis of one or more health conditions not listed on the CMS Clinical Eligibility Attestation, by requesting a review by a panel of medical professionals assigned by the CMS Managed Care Plan, to determine the child’s clinical eligibility. The Medical Review Panel shall consist of the Deputy Secretary for CMS or designee, one CMS Regional Medical Director and one CMS Regional Nursing Director. The Medical Review Panel will complete the CMS Medical Panel Review for Clinical Eligibility Determination Form DH8002-CMS (05/2016) incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX.

(5) Review Process for Clinical Eligibility Determinations.

(a) As used in this provision, “potential enrollee” means a child referred to the Children’s Medical Services Managed Care Plan for clinical eligibility determination for services whose eligibility for the CMS Managed Care Plan has not been established.

(b) Potential enrollees who have been determined not clinically eligible for the CMS Managed Care Plan after completion of the Clinical Eligibility Screening Form DH8000-CMS or CMS Eligibility Attestation DH8001-CMS and completion of the CMS Medical Panel Review for Clinical Eligibility may seek review of the ineligibility determination by filing a request for an impartial hearing with the Agency Clerk for the Department within 21 days of the receipt of notification of denial. Potential enrollees will be notified of the final medical panel review and denial by certified mail.  

(c) The request for a hearing must include the name of the applicant, the applicant’s date of birth and a detailed description of the diagnosed health condition(s) affecting the applicant. Within 15 days of receipt of the request for hearing, the Agency Clerk will forward the request to an impartial hearing officer or advise the potential applicant that the request for hearing was denied.

(d) The hearing shall be conducted by an impartial hearing officer employed or contracted by the Department. The hearing officer shall conduct the hearing and issue a written order within 50 days after the hearing officer’s receipt of the request for hearing. Timeframes may be extended by the hearing officer on request of potential enrollee. An order entered by the impartial hearing officer is final.

Rulemaking Authority 391.026(18) FS. Law Implemented 391.026(3), 391.029 FS. History–New 1-1-77, Formerly  10J-2.08, Amended 3-28-96, Formerly 10J-2.008, Amended 1-20-03, 1-11-16, Amended            .

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Cheryl Young, Director, Office of CMS Managed Care Plan and Specialty Programs

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Celeste Philip, MD, MPH, Surgeon General and Secretary

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: 05/18/2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: 03/04/2016