SMMC 3.0 Implementation: Enhanced Continuity of Care Requirements

The Agency for Health Care Administration (Agency) reminds providers that effective February 1, 2025, the new SMMC 3.0 program, which includes the delivery of behavior analysis (BA) services through the managed care delivery system, goes into effect. As part of the transition to the new SMMC 3.0 program, the Agency is requiring health plans to adhere to a continuity of care period (COC) for all services, with special COC requirements specific to BA.

The purpose of the COC period is to ensure no recipient misses a medically necessary service and providers are paid for the services they provide. As such, the Agency will ensure reimbursement for BA services to eligible recipients enrolled with a health plan.

To be reimbursed by SMMC health plans for BA services delivered during the COC period, providers must continue serving clients. The Agency has enacted the following plan requirements to ensure uninterrupted access and delivery of BA services:

·     Providers will be paid for delivering BA services during the COC period to their clients enrolled in a health plan.

·     During the COC period, health plans are required to:

Pay Medicaid enrolled BA providers for services rendered to recipients on and after 2/1/2025 who are enrolled in their plan.  

The health plans shall reimburse non-participating providers at the rate they received for services rendered immediately prior to the enrollee transitioning to the health plan for a minimum of 60 days unless negotiated otherwise. Some health plans may offer a longer period of time.

Honor existing prior authorizations and level of service for a minimum of 90 days. Some health plans may offer a longer time period.

Extend authorizations that expire prior to the end of the 90-day COC period for the remainder of the COC period.

·     Updated links to each health plan’s updated behavior analysis information can be found here.

Note: There are a small number of Florida Medicaid recipients enrolled with a managed care plan as a voluntary SMMC population; these recipients may opt to remain in the fee-for-service program at any time by opting out of managed care. Reimbursement for voluntary recipients who choose to “opt-out” of managed care will continue through the fee-for-service delivery service. More information can be found here. There are several ways that a voluntary recipient can disenroll (or opt-out) of an MMA plan:

• Phone: Medicaid Helpline at 1-877-254-1055 or Medicaid Choice Counselor at 1-877-711-3662

• Online: Beginning February 1st, 2025, you can also disenroll by visiting www.flsmmc.com 

Complaints:

·     Providers having difficulty receiving reimbursement from a health plan can file a complaint at: File a Complaint

·     Providers who wish to know more about the Grievance and Appeals process can find more information at the following highlight document: Grievance and Appeal Process Snapshot

·     Additional information on the SMMC 3.0 program beginning on 2/1/25 can be found at: New SMMC Program

Disclaimer

This information was provided by the Agency for Healthcare Administration (AHCA). The "Ask Medicaid Florida" website is intended for informational purposes only. "Ask Medicaid Florida" is not associated with any state agency including Medicaid Florida. Find all archived AHCA alerts here. Please feel free to read our full disclaimer here. If you have received this message in error, please immediately notify us at info@askmedicaidflorida.com and delete the original message. We regret any inconvenience and appreciate your cooperation.