How to File a Complaint Regarding Reinstatement to My Managed Care Plan After My Medicaid Was Terminated In Error

Overview of Florida Medicaid and Managed Care

Most Medicaid recipients are required to receive their covered services through a managed care health plan. A managed care plan shifts Medicaid recipients out of a fee-for-service delivery model (also referred to as “traditional” or “straight” Medicaid) into a managed care system where a private, for-profit company manages the recipients’ Medicaid services.

Here is a link to managed care plans in Florida, which includes but is not limited to Sunshine Health, Children’s Medical Services (currently administered by Sunshine Health), United Health Care, Aetna, Molina, and Simply Healthcare: SMMC_Plans_by_Region.pdf (myflorida.com)

You can learn more about Florida’s Statewide Medicaid Managed Care program by reviewing Section 5 of FHJP’s Advocate’s Guide to the Florida Medicaid Program. A link to that guide is here: Advocate’s Guide to Florida Medicaid – Florida Health Justice Project.

The Agency for Health Care Administration (AHCA) is responsible for managed care plan enrollment. The Department of Children and Families (DCF) is responsible for determining an individual’s eligibility for Medicaid.

What Do I Do About My Plan Enrollment When My Medicaid Is Terminated But Later Reinstated?

Sometimes a Medicaid recipient is terminated from Medicaid eligibility because DCF made a mistake. When that happens and DCF later corrects the mistake and reinstates the recipient to Medicaid, then the recipient will also need to be re-enrolled in their managed care plan to avoid a disruption in care.

In instances of a temporary loss of Medicaid eligibility due to a DCF error, which the state defines as a loss of 6 months or less, the state will re-enroll the Medicaid recipient in the same managed care plan they were enrolled in prior to the temporary loss of eligibility.

The best way to get re-enrolled back into managed care is to file an AHCA complaint. Instructions on how to file an AHCA complaint regarding this specific issue can be found below.

How to File a Complaint

Enrollees who are having trouble accessing services or who are encountering other problems with their managed care plan can file an official complaint with AHCA. These complaints are reviewed and responded to by trained staff members. For example, enrollees such as Alene, dealing with gaps in their services can file a complaint.

In addition, AHCA identifies issues that may indicate systemic problems. While some issues are not amenable to resolution through the complaint portal and may ultimately require a fair hearing, this informal complaint process is not time intensive and may result in a quick resolution.

Advocate Tip: Make sure to do this in writing and save a copy for yourself. See “Appendix 1 – AHCA Complaint via Portal”

AHCA’s online portal gives those filing a complaint the option to remain anonymous. However, if there is an issue that needs to be resolved, the person filing the complaint should be prepared to provide their name and an email address or phone number and provide documentation facilitating communication with AHCA staff, e.g., appointment of representation form, HIPAA release. There is an AHCA homepage for Florida Medicaid Complaints where you can submit a complaint or check the status of your complaint.

To File a Complaint Submit the Following Information:

Step 1

• Name
• Whether you are an “Authorized/Legal Representative, Billing Agent, Family/Friend, Government/Authorized Agency/Community Partner, Health/Dental Plan, Provider, or Recipient” 
• Your Member #, SSN, or Medicaid ID Card # 

Step 2

• Your phone number
• Address
• Email address
• Preferred Communication method and language 

Step 3 – at this time you will be given a Complaint # and an Issue #, keep these for your records

• Whether the affected person is a “Recipient, Provider, or General Population”
• You may be asked to “add person” to the file if it is not the “Recipient”
• The county where the affected person lives
• Select that the issue regards a “Health/Dental Plan”
• Select that the issue regards “Managed Medical Assistance (MMA)”
• Select the name of the Plan you had prior to DCF terminating Medicaid

At this time, there will be a series of drop downs that must be completed (Appendix 2 – Detailed Complaint Questionnaire Step 3)

• Which of the following statements best describes the situation? 
  • Select “I need help with enrolling/disenrolling or changing plans; or with selecting/changing my primary care provider or dentist”
  • Then under “Enroll/Disenroll/Change Plan” select “”I want to enroll in/disenroll from a plan or change my plan”

• You will be asked to write a brief summary to explain your complaint. 
  • You can type out your own summary but include:
    • The date DCF mistakenly terminated your Medicaid;
    • The date DCF reinstated your Medicaid;
    • That you need help being enrolled into your plan from the date you were terminated. 
  • Here is a sample summary: 

I/my child/my principal was erroneously disenrolled from Medicaid by DCF effective XXX.

On XXX, I/my child/my principal was reinstated to Medicaid effective XXX and ongoing. I/my child/my principal now needs to be reinstated to his/her managed care plan.

As a Florida managed care plan enrollee who lost Medicaid eligibility but regained it within 6 months must be immediately reinstated into my plan because I/my child/my principal regained eligibility within a “temporary loss period.”

• If it asks, “Did you speak to the plan/Medicaid Helpline about your issue?” (yes/no), note that you do not need to speak with the plan or Helpline to file the complaint. 
• Where it says, “Do you have any additional information to add prior to submitting your issue to the Agency,” you can include any necessary signed authorizations if you are acting on behalf of a principal, like a parent you care for and have power of attorney over. 
  • Below this question there will be an option to attach documents and this is where you should add your authorization, if applicable (see Appendix 1 – AHCA Complaint via Portal). 

After you have completed these steps, you will be given a preview of your entire complaint that says “You’re Almost Done!” (see Appendix 3 – Redacted Complaint Preview). Make a screenshot or copy down the information on this preview for your records.

Then click “Finish” to submit your complaint. You will be given a Complaint Reference Number in a small box that confirms your submission. Write down or take a screenshot of the reference number. You can check on the status of your Complaint at this link: status of your complaint.

Be sure to answer phone calls or return any voicemails left by AHCA staff. The best way to get the matter resolved quickly is to check the status and contact AHCA if they have not reached out to you in 1-2 business days.