The purpose of the amendment to Rule 59G-8.600, Florida Administrative Code, (F.A.C.), is to clarify the good cause reasons for which an enrollee may request to change managed care plans. The amendment updates citations from Title 42, Code of ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-8.600Disenrollment from Managed Care Plans

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-8.600, Florida Administrative Code, (F.A.C.), is to clarify the good cause reasons for which an enrollee may request to change managed care plans. The amendment updates citations from Title 42, Code of Federal Regulations (CFR), section 438.56 and clarifies requirements relating to good cause reasons.

SUBJECT AREA TO BE ADDRESSED: Disenrollment from Managed Care Plans.

RULEMAKING AUTHORITY: 409.961 FS.

LAW IMPLEMENTED: 409.969 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: May 22, 2018, 2:30 to 3:00 p.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: Margaret Dorceus. 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 DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Margaret Dorceus, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m. on May 23, 2018 and may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-8.600 Disenrollment from Managed Care 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. Requests must be submitted via telephone or in writing 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 applies to the process and reasons that SMMC managed care plan enrollees may change plans.

(2) Requests for disenrollment must be completed in accordance with sSections 409.969(2)(a) and (b), Florida Statutes (F.S.), and Title 42, Code of Federal Regulations (CFR), sSection 438.56.

(3) Good Cause Reasons.

(a) The following reasons per 42 CFR Section 438.56(d)(2) and sSection 409.969(2), F.S., and as confirmed by AHCA, constitute good cause for disenrollment from a managed care plan:

1. The enrollee is receiving a medically necessary, active, and continuing course of treatment received services within the past six months preceding a disenrollment request, from a service provider that is not in the managed care plan’s network, but is in the network of the another managed care plan requested by the enrollee.

2. The managed care plan does not cover the service the enrollee seeks because of moral or religious objections.

3. The enrollee is an American Indian or an Alaskan Native as defined in 42 CFR 438.14(a) received a notice from his or her managed care plan of a reduction in benefits following an amendment to the managed care plan’s SMMC contract.

4. The enrollee experienced a change in his or her residential or institutional provider because the LTC managed care plan changed the status of the enrollee’s provider from an in-network to an out-of-network provider, and the provider is in the network of the managed care plan requested by the enrollee.

(b) The following reasons, per 42 CFR 438.56(d)(2) and section 409.969(2), F.S., as confirmed by AHCA, constitute good cause for disenrollment from a managed care plan.when tThe enrollee must first seeks seek resolution through the managed care plan’s grievance process in accordance with 42 CFR Section 438.56(d)(5).The Agency for Health Care Administration will review the outcome of the enrollee’s grievance or appeal:

1. The enrollee is prevented from participating in the development of his or her treatment plan or plan of care.

1.2. The enrollee needs related services to be performed concurrently, but not all related services are available within the managed care plan’s network, and the enrollee’s primary care provider (PCP) has determined that receiving the services separately would subject the enrollee to unneccessary risk, and the services can be performed concurrently by a provider in the network of the managed care plan requested by the enrollee.

2.3. Poor quality of care which does not meet the quality standards established in the managed care plan’s contract with AHCA, as determined by a review of the enrollee’s medical/case records for quality, quantity, appropriateness, and timeliness of services.

3.4. Lack of access to services covered under the managed care plan’s contract with AHCA, including lack of access to medically-necessary specialty services, and access to the services is available through a provider in the network of the managed care plan requested by the enrollee.

5. The managed care plan changes the enrollee’s PCP three or more times to a new PCP at a different service location.

4. 6. There is a Llack of access to managed care plan providers credentialed by the managed care plan to provide services of the type required by the enrollee, and providers credentialed to perform the services are available in the network of the managed care plan requested by the enrollee experienced in dealing with the enrollee’s health care needs.

5.7. The enrollee experienced an unreasonable delay or denial of service pursuant to sSection 409.969(2), F.S., where or the enrollee’s service was not provided within the timely access standards or the time and distance standards established in the managed care plan’s contract with AHCA.

8. The enrollee experienced a change in their residential or institutional provider because the long-term care managed care plan changed the status of the enrollee’s provider from an in-network to an out-of-network provider.

(4) The Agency for Health Care Administration, or its designee, will review any relevant documentation submitted by the enrollee or the managed care plan regarding the disenrollment request and make a final determination determinations about whether to grant the granting disenrollment request. requests The Agency for Health Care Administration and will send written correspondence to the enrollee of any disenrollment decision. Enrollees dissatisfied with AHCA’s determination may request a Florida Medicaid fair hearing, pursuant to 42 CFR Part 431, Subpart E.

Rulemaking Authority 409.961 FS. Law Implemented 409.969 FS. History–New 2-26-09, Amended 11-8-16,________.