Effective December 18, 2017, the Agency launched a new Medicaid complaint tracking system.

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1 Effective December 18, 2017, the Agency launched a new Medicaid complaint tracking system. Complainants now choose an Allegation Statement that they feel best describes his/her issue. The complaint tracking system records these Allegation Statements as selected by the complainant, regardless of whether the reported issue is later found to be accurate or substantiated. Upon selecting an Allegation Statement, the complainant proceeds to answer a set of questions, the responses to which are used to research the reported issue. Prior to closing the complaint, assigned Agency staff selects an Allegation Category, for each reported issue. This selection is based on the actual source of the problem, as identified by Agency staff while researching the issue. The Allegation Categories will be used to help identify systemic issues, including potential plan compliance issues. The Allegation Categories correspond to the Issue Categories used in the previous complaint tracking system. The big difference is that the previous complaint system required selection of an Issue Category at intake. If a better option was later identified while researching the issue, the initial selection could not be altered. The new system requires selection of an Allegation Category, just prior to closure. This should improve reporting accuracy by allowing staff to make the best selection based on their research and all available information. Allegation Categories: Customer Service General assistance with navigation and obtaining information from the Plan or Agency Fraud Allegation Reported Provider, Member, or Health Plan Fraud General Agency/Medicaid system issues, file errors, segment updates HIPAA Reported HIPAA violation committed by Medicaid plan or network provider Marketing Violation Marketing contract violation committed by Medicaid plan Network Access Violation of Medicaid plan network access contract standards Payment Provider billed for services and claims denied, rejected or paid incorrectly by the Plan or the Agency Pharmacy Reported violation of pharmacy coverage contract requirements by Medicaid plan Services Reported problems with accessing Medicaid covered services The following report includes complaint data for the month of January The report includes the following: SMMC Managed Medical Assistance Program Issues January 2018 MMA allegations as reported to the Complaint Operations Center January 2018 Top ten MMA services identified in complaints reported to the Complaint Operations Center January 2018 Complaint trends by plan, last three months* MMA allegations closed as resolved January 2018* *These totals include issues created in the prior complaint tracking system. 1

2 SMMC Managed Medical Assistance (MMA) Program Issues Report Period: Run Date: 2/5/2018 # MMA Enrollees as of End of Month - Source: HealthTrack # of Issues Received in # of Issues, per 1,000 enrollees, # of Beneficiary Issues Resolved - # of Provider Issues Resolved - # of Issues Pending for Resolution as of run date MMA PLANS (Standard Plans) Aetna Better Health of Florida (Coventry Health Care of Florida, Inc.) 53, Amerigroup Florida, Inc. 313, Better Health, Inc. 95, Community Care Plan 42, Humana Medical Plan, Inc. 304, Molina Healthcare of Florida, Inc. 343, Prestige Health Choice 324, Simply Healthcare Plans, Inc. 75, Staywell Health Plan of Florida 642, Sunshine Health Plan, Inc. 473, United Healthcare of Florida, Inc. 262, MMA PLANS (Specialty) Children s Medical Services (CMS) 51, Clear Health Alliance HIV/AIDS Specialty Plan (Simply Healthcare Plans, Inc.) Freedom Health, Inc. Cardiovascular/ CHF/ COPD/ Diabetes Disease Specialty Plans Magellan Complete Care Serious Mental Illness Specialty Plan (Florida MHS, Inc.) Positive Healthcare Florida HIV/AIDS Specialty Plan (AHF MCO of Florida, Inc.) 9, , , Sunshine Health Plan, Inc. Child Welfare Specialty Plan 33, NON-PLAN SPECIFIC MMA System (Non-Plan Specific) Issues

3 SMMC MMA Allegations (as reported) to the Complaint Operations Center 3

4 Additional Detail for Affected Party Recipient Reported Service Related Issues Sub-Options for Allegation Statement 'I need help getting medical or dental care I need help finding a provider I need a ride for a medical appointment I was supposed to receive services from my provider, but they did not provide the service I have a provider, but the service I need was denied/ended (by plan or AHCA) I don't want to see any of the providers available I need help getting a prescription filled The quality of services I received from the provider was poor I have a provider that will see me but the provider is too far away 4

5 Complaint Trend by Plan Last 3 Months MMA Standard, and Specialty Plans 1.40 Trend by Standard Plan over last 3 months (90 day lookbacks) # of Issues, per 1,000 members As of November, 2017 As of December, 2017 As of Note: MMA Specialty Plans serve unique and divergent populations. This chart displays individual Plan trends, and is not intended for comparative analysis. 5

6 SMMC MMA Allegations Resolved - January 1, 2018 thru January 31, 2018 Standard Plans Specialty Plans ALLEGATION CATEGORY AT CLOSURE Complaints can be reported by phone at , or online at 6 Aetna Better Health of Florida Amerigroup Florida, Inc. Better Health, LLC Community Care Plan Humana Medical Plan, Inc. Molina Healthcare of Florida, Inc. Prestige Health Choice Simply Healthcare Plans, Inc. Staywell Health Plan of Florida Sunshine Health Plan, Inc. United Healthcare of Florida, Inc. Clear Health Alliance (HIV/AIDS) Children's Medical Services Network Freedom Health, Inc. (Cardiovascular, CHF, Diabetes, COPD) Magellan Complete Care (Serious Mental Illness) Positive Healthcare Florida (HIV/AIDS) Sunshine Health Plan, Inc. (Child Welfare) AHCA Total CUSTOMER SERVICE FRAUD ALLEGATION GENERAL MANAGED CARE 1 1 NETWORK ACCESS PAYMENT PHARMACY SERVICES Total: GRAND TOTAL 989