The purpose of the amendment to Rule 59G-8.600 is to clarify the requirements for good cause disenrollment, by enrollees, from Statewide Medicaid Managed Care plans. The amendment also revises the rule title to Good Cause for Disenrollment from ...

 

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, F.A.C. is to clarify the requirements for good cause disenrollment, by enrollees, from Statewide Medicaid Managed Care plans. The amendment also revises the rule title to Good Cause for Disenrollment from Managed Care Plans.

SUBJECT AREA TO BE ADDRESSED: Good Cause for Disenrollment from Health Plans.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-8.600, Florida Administrative Code, will have as provided for under sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.961 FS.

LAW IMPLEMENTED: 409.965, 409.969 FS.

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

DATE AND TIME: October 1, 2015, 10:00 a.m. ‒ 11:00 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, 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: Kelly Raborn. 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: Kelly Raborn, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop #20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]. Comments will be received until 5:00 p.m., on the date of the workshop.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT 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 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 constitute good cause for disenrollment from the managed care 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) A substantiated marketing violation, confirmed by AHCA, has 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 who 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 enrollee is in the wrong managed care plan, as determined by AHCA 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.

(g) 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).

(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.

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

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

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

(j) Poor quality of care.

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

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

(m) An unreasonable delay or denial of service.

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

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

(p) Fraudulent enrollment.

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

(r) The recipient received a notice from their plan of a reduction in required benefits at the end of the plan’s 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,__________.