DEFINITIONS Corrective Action Plan - PLEASE NOTE: Liquidated Damage - Sanction - Marketing - Enrollee Grievances and Appeals -
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1 DEFINITIONS Corrective Action Plan - In certain instances of non-compliance with the contract, the Agency may require a managed care plan to submit a corrective action plan (CAP), which is a plan to be put in place outlining how the managed care plan will remedy the non-compliance Liquidated Damage - In some cases, the Agency will impose liquidated damages in writing against the Managed Care Plan for a breach of contract. The liquidated damages are not intended to be in the nature of a penalty, but are intended to be reasonable estimates of the Agency s projected financial loss and damage resulting from the Managed Care Plan s nonperformance, including financial loss as a result of project delays. Sanction - In the event the Agency identifies a violation of or other noncompliance with the contract by a managed care plan, the Agency may sanction the Managed Care Plan. Sanctions can be monetary or nonmonetary, including, but not limited to enrollment freezes or temporary management of the managed care plan. Marketing - Actions within this category stem from noncompliance with Attachment II, Section III of the SMMC contract, and may include violations related to the following: Use of unapproved marketing materials Use of unlicensed marketing agents Marketing at unapproved events Untimely and/or Inaccurate reporting Enrollee Grievances and Appeals - Actions within this category stem from violations of Attachment II, Section IV of the SMMC contract and may include violations related to the following: Enrollee materials Grievance process Untimely and/or Inaccurate reporting Medicaid Fair Hearing - Actions within this category stem from violations of Attachment II, Section IV of the SMMC contract and may include violations related to the following: Failure of the health plan to provide a witness Failure to attend Evidentiary Materials Submit evidence packet timely FY 16/17 PLEASE NOTE: The following information relates to compliance actions issued for Q1 FY 16/17. Only actions that have been finalized are contained in the following information. Pending actions were also issued in Q1 FY 16/17, but have yet to be finalized.
2 Continuation of benefits Final order noncompliance Covered Services - Actions within this category stem from violations of Attachment II, Section V of the SMMC contract and may include violations related to the following: Service specific requirements Care coordination/case management Medical Necessity/EPSDT Untimely and/or Inaccurate reporting Provider Network - Actions within this category stem from violations of Attachment II, Section VI of the SMMC contract and may include violations related to the following: Network adequacy standards Network development and management plan Provider credentialing and contracting Provider complaint system Quality and Utilization Management - Actions within this category stem from violations of Attachment II, Section VII of the SMMC contract and may include violations related to the following: Performance measures Performance improvement projects Satisfaction and experience surveys Utilization management Untimely and/or Inaccurate reporting Administration and Management - Actions within this category stem from violations of Attachment II, Section VIII of the SMMC contract and may include violations related to the following: Organizational governance and staffing Subcontract content requirements System and data integration requirements Claims and provider payment Encounter requirements Fraud and abuse Finance - Actions within this category stem from violations of Attachment II, Section IX and X of the SMMC contract and may include violations related to the following: Financial reporting Insolvency requirements FY 16/17
3 Surplus requirements Third party resources Financial audits Untimely and/or Inaccurate reporting Reporting - Actions within this category stem from violations of Attachment II, Section II of the SMMC contract and may include violations related to the following: Ad hoc requests HIPPA reporting FY 16/17
4 Q1 FY 16/17 SMMC FINAL ACTIONS BY ISSUE TYPE AEC Total Marketing Enrollee Services and Grievances FAILURE TO COMPLY WITH ENROLLEE NOTICE REQUIREMENTS Medicaid Fair Hearing FAILURE TO PROVIDE WITNESS 1 1 FAILURE TO SUBMIT EVIDENCE PACKET 1 1 Covered Services FAILURE TO TIMELY SUBMIT REQUIRED REPORTS 1 1 Provider Network Quality and Utilization Management Administation and Management Finance FAILURE TO COMPLY WITH FINANCIAL REQUIREMENTS 2 2 FAILURE TO FILE ACCURATE REPORT 1 1 FAILURE TO TIMELY SUBMIT REQUIRED REPORTS Reporting HIPPA 1 1 Total: GRAND TOTAL: 16 TOTAL DOLLARS: $74,500 AHF/Positive Amerigroup Better CCP Clear CMSN Coventry Humana Magellan Molina Prestige Simply Staywell Sunshine United FY 16/17
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Florida Medicaid SMMC Compliance Actions Q1-Q4 FY16/17
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