The Agency for Health Care Administration (Agency) contracts with Medicaid health and dental plans to provide services to health plan enrollees. The Agency recently entered into new contracts with health and dental plans that will greatly benefit enrollees and providers. This document is part of a series that highlights the program changes in the new Statewide Medicaid Managed Care (SMMC) health and dental plan contracts. Under the new SMMC contracts, health and dental plans are required to ensure continuity of care (COC) during the transition period for Medicaid recipients enrolled in the SMMC program.
The Agency will transition to the new contracts through a regional phased roll-out 
Continuity of Care Requirements
COC requirements ensure that when enrollees transition from one health plan to another, one service provider to another, or one service delivery system to another (i.e., fee-for-service to managed care), their services continue seamlessly throughout their transition. The Agency has instituted the following COC provisions:
- Health care providers should not cancel appointments with current patients. Health plans must honor any ongoing treatment that was authorized prior to the recipient’s enrollment into the plan for up to 60 days after the roll-out date in each region.
- Providers will be paid. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Plans must pay for previously authorized services for up to 60 days after the roll-out date in each region, and must pay providers at the rate previously received for up to 30 days.
- Providers will be paid promptly. During the continuity of care period, plans are required to follow all timely claims payment contractual requirements. The Agency will monitor complaints to ensure that any issues with delays in payment are resolved.
- Prescriptions will be honored. Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days after the roll-out date in each region, until their prescriptions can be transferred to a provider in the plan’s network.
Below is additional information regarding the health and dental plans’ responsibilities:
Health Plan Responsibilities
If an enrollee was receiving a service prior to moving to a new health plan, including those services previously authorized under the fee-for-service delivery system, the enrollee’s new health plan must continue to provide that service for up to 60 days after enrollment or until:
- For Managed Medical Assistance (MMA), the enrollee’s primary care practitioner or behavioral health provider reviews the enrollee’s treatment plan. In addition, the following services may extend beyond the 60 day COC period:
- Prenatal and postpartum care for the entire course of pregnancy including postpartum care (six weeks after birth).
- Transplant Services for one year post-transplant.
- Oncology services including radiation and/or chemotherapy services for the duration of the current round of treatment.
- Full course of treatment of therapy for Hepatitis C treatment drugs.
- For Long-Term Care (LTC), the enrollee receives a comprehensive assessment, a plan of care is developed, and services are authorized and arranged as required to address the LTC needs of the enrollee.
The new plan cannot require any form of authorization and cannot require that the services be provided by a participating (in network) provider.
Health plans are also responsible for the coordination of care for new enrollees transitioning into the plan.
Dental Plan Responsibilities
Dental plans must honor any ongoing course of treatment, for at least 90 days after the dental program starts in each region if it was authorized prior to the recipient’s enrollment into the plan. Please check with the dental plans, as some have extended this period beyond 90 days.
Active orthodontic services will extend beyond the 90 day continuity of care period.
- The dental plan must continue the entire course of treatment with the recipient’s current provider.
- The dental plan must reimburse the orthodontic provider, regardless of whether the provider is in the plan’s network.
- This assumes the recipient continues to have Medicaid eligibility.
Dental plans are responsible for the coordination of care for new enrollees transitioning into the dental plan.
For more information on the SMMC program, visit: www.ahca.myflorida.com/smmc.
