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Department and CMS Regional Medical Directors Propose Clinical Eligibility Screening Tool

By Florida Department of Health, Office of Communications

November 16, 2015

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Nov. 16, 2015


Communications Office
(850) 245-4111

Tallahassee, Fla.—Today, the Florida Department of Health, with the help of the Children’s Medical Services (CMS) regional medical directors, released its proposed rule pertaining to clinical eligibility screening for the CMS Managed Care Plan (Plan). The proposed rule includes a two-part approach to clinical eligibility screening – a physician-based, auto-eligibility process using diagnostic codes for chronic and serious conditions and a parent-based survey to ensure that all Medicaid-eligible children with special health care needs are given the option to enroll in the CMS Plan.

“Progress is made when we have open, solution-focused discussions,” said Florida Department of Health Chief Operating Officer Jennifer Tschetter. “Reaching a consensus with the CMS regional medical directors on the proposed rule demonstrates the department’s commitment to working with health care professionals to get a rule in place as quickly as possible so that we can screen children with special health care needs eligible for the CMS Plan.”

In response to the list of proposed diagnostic codes presented at the Oct. 16 rulemaking workshop, the department received more than 1,000 additional diagnostic codes for consideration. Together with the CMS regional medical directors, the department analyzed each of the suggested diagnostic codes to create a revised diagnostic code list for the physician verification. The next step will be a rule hearing on Dec. 8 to receive comments and questions on the proposed rule and corresponding forms. 

"The department's proposed rule represents a reasonable approach to clinical eligibility screening by attestation of health care professionals using the ICD 10 diagnostic system for the CMS managed care plan, especially in light of the department's commitment to revisit this issue in the coming months," said Tampa Bay CMS Regional Medical Director Dr. John Curran.  "It is vitally important that we get a rule in place now so that the department can resume its clinical eligibility screening and redetermination functions for Florida’s children with special health care needs without further delay."

The department has worked in partnership with the Agency for Health Care Administration to ensure children with the most severe diagnoses are able to enroll in the CMS Plan during rulemaking. Children awaiting clinical eligibility determinations are being served through another Managed Medical Assistance plan with the same level of service agreement as the CMS Plan, or other Medicaid programs. Children currently in the CMS Plan continue to receive the high-quality care and care coordination the CMS Plan provides.

WHAT: Public Hearing on Proposed Clinical Eligibility Screening Rule

WHEN: Dec. 8, 2015
              9 a.m.

WHERE: 4042 Bald Cypress Way – Room 301
                Tallahassee, Florida 32399

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