Good Cause for Disenrollment from Health Plans

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-8.600Good Cause for Disenrollment from Health Plans

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. 28, February 11, 2016 issue of the Florida Administrative Register.

Substantial rewording of Rule 59G-8.600 follows. See Florida Administrative Register for present text.

59G-8.600 Good Cause for 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 at any time. Requests must be submitted via telephone 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 section 409.969(2)(a) and (b), Florida Statutes (F.S.) and Title 42, Code of Federal Regulations (CFR), section 438.56.

(3) Not-for-Cause Reasons. The following reasons, as confirmed by AHCA, constitute not-for-cause reasons for disenrollment from a managed care plan:

(a) The enrollee is excluded from enrollment in a managed care plan in accordance with sections 409.965, 409.972, and 409.979, F.S.

(b) The state has imposed intermediate sanctions upon the managed care plan, as specified in 42 CFR 438.702(a)(3).

(c) The enrollee missed open enrollment due to a temporary loss of Florida Medicaid eligibility.

(d) The enrollee is newly enrolled in a managed care plan and is in the first 120 days of enrollment.

(e) The enrollee meets the eligibility requirements for a specialty plan and requests enrollment.

(f) The enrollee is in his or her annual open enrollment period.

(4) Good Cause Reasons.

(a) The following reasons, as confirmed by AHCA, constitute good cause for disenrollment from a managed care plan:

1. 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.

2. The enrollee 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 another managed care plan.

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

4. The enrollee 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.

5. The enrollee experienced service access impairments due to service availability exceeding the timely access standards in the managed care plan’s SMMC contract.

6. Except as specified in this rule, other reasons per 42 CFR 438.56(d)(2) and section 409.969(2), F.S.

(b) The following reasons, as confirmed by AHCA, constitute good cause for disenrollment from a managed care plan. The enrollee must first seek resolution through the managed care plan’s grievance process:

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

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 unnecessary risk.

3. Poor quality of care.

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.

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

6. There is a lack of access to health plan providers experienced in dealing with the enrollee’s health care needs.

7. The enrollee experienced an unreasonable denial of service, or the enrollee’s service was not provided with reasonable promptness as set forth in Title 42, United States Code, subsection 1396a(a)(8).

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.

(5) The Agency for Health Care Administration, or its designee, will make final determinations about granting disenrollment requests and will send written correspondence to the enrollee of any disenrollment decision. Enrollees dissatisfied with the determination may request a Florida Medicaid fair hearing, pursuant to 42 CFR Part 431, Subpart E.

Rulemaking Authority 409.961 FS. Law Implemented, 409.965, 409.969 FS. History–New 2-26-09, Amended,__________.