Medicaid Quality

Melissa Vergeson
Bureau Chief

2727 Mahan Drive
Mail Stop #38
Tallahassee, FL 32308

Phone: (850) 412-4005

The Quality Bureau provides data-driven, focused and systematic feedback on the quality of Florida’s Medicaid program to federal and state agencies, Medicaid recipients, Medicaid managed care plans, and providers. Florida’s 2014 transition from a mix of fee-for-service and managed care to mostly managed care hastened a newly-honed focus on quality: providing more comprehensive care, improving health outcomes, and reducing costs.

The Quality Bureau is responsible for the following:
  • Quality measurement and improvement
  • Research and evaluation of Medicaid managed care plans
  • Monitoring Medicaid managed care clinical outcomes
  • Oversight of prior authorization of services
  • Management of remaining Medicaid fee-for-service programs
  • Providing clinical consultation to the entire Agency

Federal Reports

The State of Florida is required to furnish a written quality strategy to the federal Centers for Medicare and Medicaid Services (CMS) every three years.  This report must include a written quality strategy for assessing and improving the quality of health care and services furnished by the managed care organizations and other providers within Florida Medicaid.  The Medicaid Quality Bureau of the Agency for Health Care Administration (the Agency) is compiling a new Comprehensive Quality Strategy (CQS) report, outlining Florida Medicaid’s priorities and goals for continuous quality improvement, the performance improvement efforts that align with and promote these priorities/goals, and the quality metrics and performance targets to be used in measuring performance and improvements to provide “better health care for all Floridians”.

A copy of the draft 2020 report is located at the following link:: Comprehensive Quality Strategy Report.

Performance Measurement & Quality Review

  • Establishes performance benchmarks for Medicaid managed care plans and analyzes results.
  • Leads managed care quality improvements.
  • Monitors specific programs for improvement opportunities.
  • Produces the Medicaid Health Plan Report Card comparing Medicaid Managed Medical Assistance (MMA) plans.

Clinical Compliance Monitoring

  • Provides clinical review of Statewide Medicaid Managed Care program services, policies, procedures, reports and initiatives.
  • Performs targeted contractual compliance monitoring of Medicaid Managed Medical Assistance Plans and Dental Plans.
  • Monitors Medicaid special population programs including School Match and Administrative Claiming, the Model Waiver and Familial Dysautonomia Waiver.
  • Participates in inter-agency child staffing meetings for medical neglect, behavioral health services and the Children’s Multidisciplinary Assessment Team.

Quality Improvement & Evaluation Contracts

  • Ensures that Medicaid recipients not enrolled in managed care plans receive medically necessary, quality services in the most cost-effective manner.
  • Manages prior authorization and utilization management contracts.
  • Conducts monitoring and technical assistance for FFS programs.