Eligibility for CMS Network Services

Notice of Change/Withdrawal

 

DEPARTMENT OF HEALTH

Division of Children's Medical Services

RULE NO.:RULE TITLE:

64C-2.002Eligibility for CMS Network Services

 

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. 42, No. 104, May 27, 2016 issue of the Florida Administrative Register.

These changes are in response to written comments submitted by the Joint Administrative Procedures Committee staff: As to Form DH8001-CMS (05/2016), replace “attest” with “certify” on page 5; remove “encrypted” from page 6. The following phrase is added to the form: “Parent or guardian acknowledges that emailing is an unsecured method of communication which may result in the unauthorized access of protected health information by third parties.”

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

(1) through (3) No change.

(4) Application may be made for children with a diagnosis of one or more health conditions not listed on the CMS Clinical Eligibility Attestation form, 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) No change.

(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 petition 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 determination and denial by certified mail as well as their right of appeal.

(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.

(c)(d) AThe hearing shall be conducted by an impartial hearing officer employed or contracted by the Department in accordance with section 120.80(15), F.S. 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.