Quality Management Contracts
The following Medicaid services are subject to quality management review:
- Statewide Inpatient Psychiatric Program Services (SIPP) - Magellan
- Home and Community Based Waiver Services for the Developmentally Disabled - Qlarant
- Home Health Services - Netsmart
- Healthy Start Services – Healthy Start MomCare Network
- Preadmission Screening and Resident Review (PASRR) - Kepro
- Regional Perinatal Intensive Care Centers (RPICC) - UF
- Pharmacy Benefits Managers (PBMs) – Myers and Stauffer
- American Rescue Plan Act (ARPA) – Florida’s HCBS Spending Plan – Myers and Stauffer
- Prior Authorization of Medicaid services – eQHealth Solutions
- Enhanced Home Care for the Elderly Program (eHCE) – Area Agencies on Aging
Magellan provides Care Coordination Services for fee-for-service Florida Medicaid recipients receiving treatment within an in-state or out-of-state residential provider setting. Care coordination consists of treatment plan review, discharge planning and aftercare follow-up. The Vendor ensures that Florida Medicaid recipient children do not remain in long-term residential care if it is not medically necessary. The goal of the Program is to ensure that the recipient returns to their home community successfully.
Agency Contact: Cathy Cross
Qlarant Quality Solutions is a Quality Improvement Organization (QIO)-like entity that provides the Florida Statewide Quality Assurance Program (FSQAP) for the Developmental Disabilities Individual Budgeting (iBudget) and Consumer Directed Care Plus (CDC+) programs. Qlarant works in partnership with the Agency for Persons with Disabilities (APD) at the state and regional offices to improve the quality of supports for Medicaid recipients with developmental disabilities. The FSQAP measures the success of services and supports from the blended perspectives of both the individual receiving services as well as program measures and requirements and uses quality improvement strategies to promote a person-centered service delivery system.
Agency Contact: Suzi Kemp
Healthy Start MomCare Network, Inc., Section 409.906, Florida Statutes (F.S.). directs the Agency for Health Care Administration (Agency) to contract with an administrative services organization (ASO) representing all Healthy Start Coalitions, providing risk appropriate care coordination and other services in accordance with applicable statutes and federal waiver(s). The primary purpose of the Healthy Start Program is to increase the delivery of effective, evidence-based services that reduce infant mortality, reduce the number of low-birth-weight infants and improve health and developmental outcomes for Florida Medicaid enrollees.
Agency Contact: Suzi Kemp
Kepro administers the Preadmission Screening and Resident Review (PASRR), a federally required review mandated by the Social Security Act, Title 42, Subpart C, Sections 483.100 through 483.138, Code of Federal Regulations. PASRR is intended to ensure that Medicaid-certified nursing facility applicants and residents with a diagnosis of, or suspicion of, serious mental illness (SMI), or intellectual disability and related conditions (ID), or both, are identified. A PASRR is required for all applicants to, and residents of, Medicaid-certified nursing facilities, regardless of payor.
Agency Contact: Cathy Cross
eQ Health Solutions provides prior authorization, retrospective review, and medical review/consultation services for Florida’s roughly 800,000 Medicaid recipients receiving services through the fee-for-service delivery system. Section 409.912(13), Florida Statutes (F.S.) mandates the implementation and operation of a utilization management for the Agency that provides PA authorization for Florida’s Medicaid recipients receiving services through the fee-for-service delivery system. eQ Health provides prior authorization for: behavior analysis services (regardless of plan enrollment), durable medical equipment, hearing services, home health, inpatient medical and surgical hospitalizations, emergency hospitalizations (Balanced Budget Act and non-citizens), Out-of-state services, practitioner services, prescribed pediatric extended care (regardless of plan enrollment), radiology and nuclear medicine, diagnostic imaging, special services (EPSDT), statewide inpatient psychiatric services, therapy services, and visual services. The Vendor provides care coordination for medically complex children receiving home health, personal care, prescribed pediatric extended care, private duty nursing, skilled nursing, and waiver services, and administers fraud and abuse monitoring through special projects and analysis.
Agency Contact: Latoya Clark
Netsmart Technologies Section 409.9132, Florida Statutes (F.S.) mandates the implementation and operation of an Electronic Visit Verification (EVV) Program of home health visits (HH), private duty nursing (PDN), and personal care services (PCS) rendered by fee-for-service (FFS) home health providers. The objective of the EVV program is to verify the delivery of services rendered by fee-for-service home health providers and deter fraudulent or abusive billing for the service. The program must verify visits for the delivery of home health services by using technology that is effective for identifying delivery of the home health services, deterring fraudulent or abusive billing for these services, and provide an electronic billing interface for home health services.
Agency Contact: Latoya Clark
Myers and Stauffer provide auditing and analytical services for the following two Quality Management contracts.
- Auditing and reporting services for the Florida HCBS Spending Plan (ARPA) , ensuring the enhanced FMAP funding is used to recruit and retain staff to care for recipients of HCBS services.
Agency Contact: Latoya Clark
- Auditing and analysis of PBMs contracted with the SMMC health plans operating in the state of Florida, as directed by EO 22-164[
], to determine if recipients received, and the state paid for cost-effective prescriptions in the last five years.
Agency Contact: Suzi Kemp
The University of Florida coordinates and maintains the Regional Perinatal Intensive Care Centers (RPICC) Program, a comprehensive, statewide, high-risk neonatal/obstetrical health care delivery system as required by Section 383.19(2), F.S. The purpose of the Contract is for the procurement and maintenance of a proprietary global payment system to facilitate reimbursement to RPICC providers. The RPICC program contains demographic and medical information on high-risk pregnant women and newborns that receive intensive care services in the eleven regional centers in Florida. The program is administered by the Department of Health (DOH), Children’s Medical Services (CMS).
Agency Contact: Cathy Cross
