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

 

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 and incorporate the requirements of Rules 59G-14.002-14.007, F.A.C., as appropriate. The amendment also revises the rule title to Florida Kidcare Dispute Review and Grievance Process.

SUBJECT AREA TO BE ADDRESSED: Definitions.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-14.001, F.A.C., will have as provided for under sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.818 FS.

LAW IMPLEMENTED: 409.818 FS.

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

DATE AND TIME: February 25, 2016, 10:00 a.m. – 11:00 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room A, 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 DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Angela Wiggins, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT 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, enrollment, and health care services for the Title XXI, Children’s Health Insurance Program (CHIP). This rule will specify program requirements in accordance with Title 42, Code of Federal Regulations (CFR), sections 457.1130-457.1180.

(2) Confidentiality. The Process conforms to section 409.821, Florida Statutes (F.S.), the Health Insurance Portability and Accountability Act of 1996, and 42 CFR, Part 431, Subpart F, with respect to confidentiality of information.

(3) Definitions. The following definitions are applicable to the Title XXI, Florida Kidcare pPrograms (Florida Department of Health’s (DOH) Children’s Medical Services Managed Care Plan Network (CMS Managed Care Plan), Florida Healthy Kids, and Medikids MediKids) and to all sections of Florida Kidcare Grievance Procedures, Chapter 59G-14, F.A.C. These definitions do not apply to any complaint or grievance issues relating to Florida Medicaid 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 denial of eligibility, suspension or termination of enrollment, or disenrollment for failure to pay the premium.

(b) Children’s Medical Services Managed Care Plan(CMS Managed Care Plan) Integrated Care System (ICS) – Contracted entity providing administrative services including provider network contracting, service authorizations, quality improvement programs, and first level complaints and appeals for CMS. 

(c) CMS Managed Care Plan Statewide Grievance Panel – Entity responsible for reviewing the appropriateness of the appeal decisions for enrollees who receive health services for which an ICS is not responsible, and making a recommendation to the Deputy State Health Officer (DSHO) for the CMS Managed Care Plan. 

(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.

(d)(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, complaint, 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).

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

(f)(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.

(g)(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.

(h) Florida Healthy Kids Corporation (Corporation) – Designated eligibility processor for the CHIP program. The Corporation is also responsible for conducting the dispute review process, preparing all written responses to the complainant, and addressing health service disputes or complaints with the Corporation’s managed care plans.

(i) Grievance – Written request to review an eligibility or enrollment decision after the dispute review process has been completed. Complaints involving an eligibility or enrollment dispute between the Department of Children and Families (DCF) and the Corporation will proceed directly to the grievance level.

(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.

(j)(9) “Florida Kidcare Grievance Committee (Committee) – ” or “committee” is the Eentity responsible for hearing and resolving grievances related to CHIP. The Committee consists of one representative from each of the following agencies:

1. Agency for Health Care Administration (AHCA) (Committee chair)

2. DCF

3. DOH

4. Florida Covering Kids and Families

5. Florida Healthy Kids Corporation

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.

(k) (11) “Health Services – ” means the Mmedical and dental benefits provided by the enrollee’s an individual’s health plan coverage (e.g., hospital services, physician services, prescription drugs and laboratory services).

(l) Quality Improvement Organization (QIO) – Organization certified through the Centers for Medicare and Medicaid Services, Office of Clinical Standards and Quality, to perform medical and utilization review functions.

(m) Reconsideration – Review of an adverse determination previously rendered by the QIO, at the request of the provider or Medikids enrollee.

(n) Subscriber Assistance Program – State external conflict resolution program authorized under section 408.7056, F. S., that provides an additional level of appeal if the health plan does not resolve the grievance.

(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.

(4) Dispute Review Process. Disputes relating to eligibility, enrollment, and health care services for CHIP are conducted in accordance with time frames required by 42 CFR 457.1160. Each CHIP program reviews and resolves health service matters through the processes described in section (7) of this rule.

(a) The dispute review process begins when the Corporation receives a dispute from a complainant. The Corporation will take the following actions for disputes received within ten working days of the adverse action notice:

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.

(b) The complainant is responsible for paying back all premiums and the costs of services rendered during the continuation period if the dispute is resolved in favor of Florida Kidcare.

(c) The Corporation must comply with the following time frames, upon receipt of the dispute:

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

2. Render a written decision within 15 calendar days

(d) 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. 

(e) The complainant will be notified of the approval or denial of the continuation of enrollment by the Corporation.

(f) The complainant may appeal the dispute review process decision to the Corporation’s Chief Executive Officer (Officer) or designee, if dissatisfied. The Officer will notify the complainant of his or her decision in writing within ten calendar days of the complainant’s dispute review decision appeal request, and provide information regarding additional appeal rights. 

(g) The complainant may appeal the Officer’s decision by submitting a grievance request through the Corporation to AHCA, within ten calendar days of the 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.

(5) Grievance Process.

(a) The Agency for Health Care Administration will send notice acknowledging receipt of the grievance to the complainant and a request for any additional information, if needed, within five calendar days of receipt. 

(b) Upon the complainant’s request, AHCA will send a copy of the dispute review file to the complainant within five calendar days of the request.

(c) If a complainant chooses to have someone represent them during the grievance process, the following forms must be requested from AHCA: Appointment of Representation Form, AHCA Med-Serv Form 017 and the Authorization for Use and Disclosure of Protected Health Information Form, AHCA Med-Serv Form 018, August 2007, incorporated by reference. These forms will be sent to the complainant within five calendar days of the request. If the complainant does not return the completed representation forms to AHCA within ten calendar days, the grievance process will continue based on the contents of the dispute review file.

(d) The Agency for Health Care Administration will provide written notification to the complainant that the review process decision remains unchanged, within twenty calendar days of receiving the grievance documentation, inclusive of all required forms, when it agrees with the dispute review decision.

(6) Grievance Committee Meeting.

(a) If AHCA determines that further consideration of the decision is needed, the Committee will schedule a meeting to hear the grievance. The Agency for Health Care Administration will send a meeting notice to the complainant or the complainant’s appointed representative notifying them of the date, time, and location of the Committee meeting. 

(b) The complainant may participate in the Committee meeting or appoint an authorized representative for the grievance process. The complainant and their representative are responsible for the costs associated with attending or participating in the Committee meeting. If necessary, AHCA will arrange for participation by telephone. 

(c) Committee members or their designee(s) are required to attend meetings or participate by telephone.

(d) The Committee decides by a verbal majority vote. The decision of the Committee is final and all Florida Kidcare partners must abide by the decision. The complainant is notified in writing of the Committee’s decision within ten calendar days of the committee meeting. 

(7) Health Services Disputes.

(a) Complainants must submit health services disputes in accordance with each Florida Kidcare program’s health services dispute process.

(b) Each Florida Kidcare program entity has developed its own procedure for resolving health services disputes, as follows:

1. Corporation – When a complainant sends the Corporation a written health services dispute, the Corporation forwards the dispute and all pertinent information to the health plan. The Corporation must confirm and document that appropriate action has been taken within twenty calendar days of receipt of the complainant’s dispute.

2. Medikids – Complainants may file an appeal directly with the enrollee’s health plan.

3. Children’s Medical Services Managed Care Plan –Complainants may submit health services disputes to the CMS Managed Care Plan Integrated Care System for ICS-provided services. The ICS Appeal Committee will review the dispute. Complainants may submit non-ICS health services disputes to the CMS Managed Care Plan area office. The regional CMS Plan Appeal Committee will review these health services disputes.

(8) Appeals. 

(a). Complainants may appeal decisions made by the Corporation’s or Medikids’ health plans through the Subscriber Assistance Program.

(b) Complainants dissatisfied with health services decisions rendered by AHCA’s QIO may file an appeal directly with the QIO to request reconsideration.

(c) Complainants dissatisfied with the ICS Appeal Committee’s or the regional CMS Managed Care Plan Appeal Committee’s decision may request a CMS Managed Care Plan Statewide Grievance Panel review. The CMS Managed Care Plan Statewide Grievance Panel will review the dispute and make a recommendation to the Deputy State Health Officer. The decision of the DSHO is final for all health service issues.

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