AHCA: Statewide Medicaid Managed Care Program

CARES Long-Term Care Transition Referral Form and Instructions [ 25 kB ]

Web site updated with this material 3/25/2022.
CI 2022-01 Transition of Care (issued 3/24/2022) [ 143.6 kB ]

Case Management File Audit Report Operational Guidelines [ 35.1 kB ]

Web site updated with this material 2/14/2022.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section XVI.A.1., Table 9

Child Health Screenings Periodicity Schedule

Web site updated with this material 9/20/2018.
2018-2023 Dental Contract Citation: Attachment II, Section VI.E.2.a.
2018-2023 Dental Contract Citation: Attachment II, Section VI.E.2.b.(3)
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.D.3.b.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.D.3.c.(4)

Comprehensive Hemophilia Disease Management Program

Web site updated with this material 9/20/2018.
2018-2023 MMA Contract Citation: Attachment II, Exhibit, II-A, Section V.A.1.a.(16)(i)
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.C.4.

Consent for Voluntary Suspension of Authorized Services Template in the Statewide Medicaid Managed Care Program Form [ 39.7 kB ]

Web site updated with this material 9/20/2018.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.4.b.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.E.6.b.

Disclosure of Ownership and Control Interest Statement [ 172.7 kB ]

Web site updated with this material 1/14/2019.
2018-2023 Health/Core Contract Citation: Attachment II, Section XV.C.4.i.
2018-2023 Dental Contract Citation: Attachment II, Section XV.C.6.

Enrollee Handbook Template for Dental Benefits [ 83.9 kB ]

Enrollee Handbook Template Instructions for Dental Benefits
Web site updated with this material 7/12/2021.
2018-2023 Dental Contract Citation: Attachment II, Section V.B.8.a.

Enrollee Handbook Template for Enrollees with MMA and LTC Benefits [ 300.8 kB ]

Enrollee Handbook Template Instructions for MMA and LTC Benefits
Web site updated with this material 7/12/2021.
2018-2023 Health/Core Contract Citation: Attachment II, Section V.B.8.a.

Encounter Notification Service (ENS) Through Florida’s Health Information Exchange

Web site updated with this material 9/20/2018.
2018-2023 MMA Contract Citation: Attachment B, Exhibit II-A, Section VIII.A.6.a.(3)

Florida Medicaid Pregnancy Notification Form [ 140.3 kB ]

Optional

Web site updated with this material 12/06/2022.

Freedom of Choice Certification for Children in Nursing Facilities for Florida Statewide Medicaid Managed Care (SMMC) Program [ 771.4 kB ]

Website updated with this material 3/08/2024.
2018-2024 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.5.
2018-2024 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.E.8.

Freedom of Choice Certification Form for Enrollees with MMA and LTC Benefits [ 34.4 kB ]

Web site updated with this material 9/20/2018.
2018-2023 Health/Core Contract Citation: Attachment II, Section VI.E.3.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.5.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.E.8.

Freedom of Choice Survey for Children Receiving Private Duty Nursing (PDN) Who Have Been Referred to the Children’s Multidisciplinary Assessment Team (CMAT) [ 215.2 kB ]

Website updated with this material 3/06/2024.
2018-2024 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.E.5.

Health and Dental Plan Privacy Incidents/Breaches Reporting Form [ 914.6 kB ]

Web site updated with this material 7/15/2020.
2018-2023 Contract Citation: Attachment II, Exhibit A-8 Standard Contract, Business Associate Agreement

HIV-AIDS Algorithm & HIV-AIDS Algorithm Drug Codes

Web site updated with this material 11/1/2024.
HIV-AIDS Algorithm [ 67.6 kB ] - November 1, 2024.

Hospital Termination Checklist [ 20.2 kB ]

Web site updated with this material 7/29/2021.
PT 2021-19 [ 50.5 kB ] issued June 11, 2021

In Lieu of Service (ILOS) Submission Form for SMMC Managed Care Plans [ 42.7 kB ]

SMMC ILOS Plan Submission Review AHCA Checklist [ 33.9 kB ]
Web site updated with this material 1/4/2022.
2018-2023 Health/Core Contract Citation: Attachment II, Section VI.D.2.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VI.A.2.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.A.2.b.

Marketing Requirements

Marketing Operational Guidelines [ 671.5 kB ] Added 4/8/2022
Marketing Guidelines Training [ 2.8 MB ] Added 4/8/2022
Marketing Materials Notice of Submission [ 39.2 kB ]
Web site updated with this material 4/8/2022.
2018-2023 Health/Core Contract Citation: Attachment II, Section IV.A.2.
2018-2023 Health/Core Contract Citation: Attachment II, Section IV.G.
2018-2023 Dental Contract Citation: Attachment II, Section IV.A.2
2018-2023 Dental Contract Citation: Attachment II, Section IV.G.
Website updated with this material 3/2/2023.

MMA Physician Incentive Program (MPIP)

Web site updated with this material 9/20/2018.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VIII.E.1.
Section 409.967(2)(a), Florida Statutes

Multiple Signature Verification Agreement Form [ 90.7 kB ] Effective 12/3/2024

Web site updated with this material 12/3/2024.
2018-2023 Health/Core Contract Citation: Attachment II, Section XII.A.1.b.
2018-2023 Dental Contract Citation: Attachment II, Section XII.A.1.b.

Multiple Signature Verification Agreement Form for Custody Arrangement [ 156.3 kB ] Effective 12/3/2024

Web site updated with this material 12/3/2024.
2018-2023 Health/Core Contract Citation: Attachment II, Section XII.A.3.c.
2018-2023 Dental Contract Citation: Attachment II, Section XII.A.3.c.

Notice of Adverse Benefit Determination (NABD) Template for Enrollees with LTC Benefits [ 40.8 kB ]

Web site updated with this material 8/30/2024.
2018-2024 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
2018-2024 LTC Contract Citation: Attachment II, Exhibit II-B, Section VI.G.1.k.
2018-2024 LTC Contract Citation: Attachment II, Exhibit II-B, Section IX.E.3.a.(18)

Notice of Adverse Benefit Determination (NABD) Template for Enrollees with MMA and Dental Benefits [ 42 kB ]

Web site updated with this material 8/30/2024.
2018-2024 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
2018-2024 MMA Contract Citation: Attachment II, Exhibit II-A, Section VII.E.1.

Notice of Adverse Benefit Determination (NABD) Template for MediKids [ 41.3 kB ]

Web site updated with this material 8/30/2024.
2018-2024 Health/Core & Dental Contract Citation: Attachment II, Section VII.E.
2018-2024 MMA Contract Citation: Attachment II, Exhibit II-A, Section VII.E.1.

Notice of Plan Appeal Resolution (NPAR) Template [ 29.4 kB ]

Web site updated with this material 9/20/2018.
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section VII.I.1.

Notice of Plan Appeal Resolution (NPAR) Template for MediKids Enrollees [ 33.1 kB ]

Web site updated with this material 1/6/2025.
2018-2024 Health/Core & Dental Contract Citation: Attachment II, Section Vll.I.1.

Notice of Status Letter Template [ 19.6 kB ]

Web site updated 10/27/2021.
PT 2021-27 [ 49.5 kB ] issued Aug. 27, 2021.
2018-2023 Health: Attachment II, Section VIII.D.5.d.(3)
2018-2023 Health: Attachment II, Section VIII.D.5.e.(3)
2018-2023 Dental: Attachment II, Section VIII.D.5.d.(3)
2018-2023 Dental: Attachment II, Section VIII.D.5.e.(4)

Participant Direction Option (PDO) for Enrollees Receiving LTC Benefits

PDO Consent Form [ 36.7 kB ] - May 2022
PDO Evaluation [ 28.7 kB ] - May 2022
PDO Guidelines [ 334.5 kB ] - May 2022
PDO Pre-Screening Tool [ 51.8 kB ] - May 2022
PDO Representative Agreement [ 51.5 kB ] - August 2022
PDO Timesheet Attestation Language [ 24.2 kB ] - July 2018

Participant Direction Option (PDO) for Plans Providing LTC Benefits

PDO Manual [ 117 kB ] - May 2022
Training Webinar Presentation [ 502.1 kB ] - January 16, 2019
Web site updated with this material May 25, 2022.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section Vl.A.3.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VIII.C.2.c.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section VIII.C.2.e.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.c.(5)
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.d.(9)
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.B.5.e.(2)
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section X.C.1.b.

Performance Measures for the Long-Term Care Waiver

Web site updated with this material 9/20/2018.
2018-2023 LTC Contract Citation: Attachment II, Exhibit II-B, Section IX.B.2.b.

Pharmacy Lock-In Policy [ 80.3 kB ]

Web site updated with this material 9/20/2018.
2018-2023 MMA Contract Citation: Attachment II, Exhibit, II-A, Section VI.A.1.a.(16)(g)

Requirements for Provision of Oral and Written Material in Different Languages

Web site updated with this material 2/18/2022.
PT 2021-13 Non-Discrimination Compliance Requirements [ 105.4 kB ] , Issued May 4, 2021
2018-2023 Health/Core Contract Citation: Attachment II, Section V.A.5.
2018-2023 Dental Contract Citation: Attachment II, Section V.A.6.
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.B.2.
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.B.9.a.(7)
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.C.1.b.
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section V.C.2.
2018-2023 Dental Contract Citation: Attachment II, Section IX.E.3.a.(3)
2018-2023 Health/Core Contract Citation: Attachment II, Section IX.E.3.a.(3)-(4)
2018-2023 Health/Core & Dental Contract Citation: Attachment II, Section X.B.6.

Serious Mental Illness (SMI) Algorithm & SMI Algorithm Diagnosis and Drug Codes

Web site updated with this material 11/1/2024.
SMI Algorithm Diagnosis and Drug Codes [ 2.3 MB ] - November 1, 2024.

Train-the-Trainer Program

Web site updated with this material 10/29/2024.
Care Coordination Training Day 1 (Part 1)
Care Coordination Training Day 1 (Part 2)
Care Coordination Training Day 2
Care Coordination Training - Train the Trainer Slide [ 11.6 MB ]
Module 1A Facilitation Guide CC Trainings [ 432.9 kB ]
Module 1B CC Training PowerPoint [ 2.3 MB ]
Module 1C Assessment [ 364.8 kB ]
Module 2A Facilitation Guide CC Trainings [ 486.6 kB ]
Module 2B CC Training PowerPoint [ 2.2 MB ]
Module 2C Assessment [ 424.2 kB ]
Module 2D SAMPLE Transition Plan [ 345.1 kB ]
Module 3A Facilitation Guide CC Trainings [ 548.5 kB ]
Module 3B CC Training PowerPoint [ 1.6 MB ]
Module 3C Assessment [ 484.5 kB ]

Unborn Activation and Newborn Enrollment Requirements

Web site updated with this material 2/23/2022.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section III.C.1.a.-b.
2018-2023 MMA Contract Citation: Attachment II, Exhibit II-A, Section VIII.C.4.a.(5)

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SMMC 2018-24: Agency-Approved Contract Materials