• Advocate's Guide to the Florida Long-Term Care Medicaid Waiver

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    Prepared by:

    Miriam Harmatz | Co-Executive Director, Florida Health Justice Project

    Katy DeBriere | Co-Executive Director, Florida Health Justice Project

    Michelle Adams | Research Assistant, Florida Health Justice Project

    Jocelyn Armand | Advocacy Director, Legal Services of Greater Miami

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    Look at The Advocate's Guide to the Florida Medicaid Program

  • Table of Contents

    Section 1: Introduction

    • Why This Guide?
    • Purpose of the Guide

     

    Section 2: Background

    • What are Medicaid Waivers?
    • History and current status of Florida's Long-Term Care Waiver


    Section 3: Waiver Overview

    • Different Agencies
    • Waiver Populations
    • Role of the Managed Care Plan

     

    Section 4: What Eligibility Standards Apply to the LTC Program?

    • Clinical
    • Financial
     
    • Application Steps
     
    • Initial Assessment / Priority Rank
    • After Release From Waiting List
     
    • Picking a Plan
     
    • "Good Cause"
    • Exemptions from the LTC Waiver
     
    • Initial Contact
    • Person-Centered Planning Process
    • Person-Centered Plan of Care
    • Supplemental Assessment
    • Role of Case Management
    • Reassessment
    • Participant Directed Services
     
     
     
     
     
    • Timely Access Standards
    • Care Coordination and Continuity
     
    • Filing and AHCA Complaint
    • Grievances, Appeals, and Fair Hearings
    • What is an Adverse Benefit Determination (ABD)
    • What Notice Requirements Apply?
    • Fair Hearings
     
     
     
     
     
     
  • Acknowledgments

    We want to thank Nancy Wright, a leading Florida expert on the state’s Medicaid Long-Term Care Waiver and Eric Carlson, Directing Attorney at Justice in Aging, and a leading national expert on Medicaid long-term services and supports and home and community-based waivers. Not only was this Guide made possible thanks to their previous work, but they also spent hours reviewing and editing our drafts. Major thanks are also due to Joseph Schieffer, Project Manager with Florida Justice Technology Center (FJTC) and an expert in innovative technology. Joseph spent hours preparing a web-based version of this Guide, maximizing its usefulness for advocates and consumers.

     

    We also want to thank our co-authors Jocelyn Armand, Advocacy Director of Legal Services of Greater Miami and Michelle Adams for their invaluable help and support in preparing the Guide.

    Thanks are also due to Valory Greenfield, staff attorney with Bay Area Legal Services Florida Senior Legal Helpline and Anne Swerlick, Florida Medicaid expert and Health Policy Analyst with the Florida Policy Institute who consulted on making the Guide more useful for Florida advocates serving seniors needing long-term services and supports and to FJTC’s Alison DeBelder, FLAdvocate’s Engagement Manager, who helped share this resource with the Florida advocacy community.

     

    Finally, we are deeply grateful to Sarah Halsell, State Legal Services Developer with the Florida Department of Elder Affairs (DOEA). Sarah’s commitment to creating additional resources for Florida’s advocates, along with critical financial support from the U.S. Administration for Community Living Model Approaches to Statewide Legal Assistance Systems, made this Guide possible.


     
    Miriam Harmatz and Katy DeBriere
    Co-Directors, Florida Health Justice Project

     

    August 29, 2018

  • Section 1: Introduction

    Why this Guide?

    It goes without saying that government-subsidized health care benefits are critical for low-income Florida seniors—particularly those who are frail and disabled.


    This Guide concerns one of the most important health care benefits for this population— the long-term services and supports (“LTSS”) that are essential to being able to remain in one’s home or community rather than having to receive care in a nursing home. Also known as “home and community-based services,” (“HCBS”), these include services not typically available through Medicare or standard medical insurance, such as personal care aides and private duty nursing. Nationwide, over half of people turning 65 will at some point develop a severe disability or medical condition that will require HCBS.1

     
    In Florida, HCBS for adults are available under the Statewide Medicaid Managed Care system. Long-term care – including both nursing home care and HCBS –are both part of Florida’s “Long-Term Care Program.”2 This Guide, however, focuses exclusively on the portion of the LTC Program that provides HCBS, (the “LTC Waiver.”) While the LTC Waiver has a cap on the number of individuals served and a wait list for enrollment3, that should not deter individuals from applying.

    Purpose of the Guide

    This Guide provides advocates with an overview of the authority governing Florida's Medicaid Managed Care Long-term Care (LTC) Waiver and a roadmap addressing basic questions including:

    • Who is eligible for the LTC Waiver
    • How to apply
    • What to do if an application is denied or delayed
    • How does the wait list work
    • What to do if eligibility is terminated
    • What services are covered and how is the “care plan” developed
    • How does managed care work
    • What to do if services are denied, delayed, terminated or reduced
  • Section 2: Background

    What are Medicaid Waivers?

    Under waiver programs, states can “waive” certain requirements under the Medicaid Act with permission of the federal government. For example, a waiver program allows states to provide care for people who might not otherwise be eligible under Medicaid; provide services that are not necessarily medical in nature, or implement a managed care system. Florida’s current Long-Term Care Waiver operates through two separate waivers authorized under Social Security Act Sections 1915(b) (for managed care) and (c) (HCBS).


    Section 1915(c), authorizing Medicaid HCBS waivers, was enacted by Congress in 1983. HCBS waivers allow states to provide home and community support services to a specified number of individuals as an alternative to institutional care.4 All individuals enrolled in a HCBS waiver must meet an institutional level of care.5

     

    To facilitate these programs, the federal government can waive general Medicaid rules that programs be available throughout a state (statewideness) and to all eligibility groups (comparability), and offer more lenient financial eligibility standards.6 In addition, Section 1915(b) of the Social Security Act provides authority allowing states to require enrollment in managed care by waiving the rule that beneficiaries are free to choose their providers.7

     

    Because states are allowed to limit enrollment in HCBS waivers,8 eligible individuals who meet the clinical and financial eligibility requirements for HCBS can nonetheless be put on a waiting list. By contrast, similarly eligible individuals seeking nursing home placement cannot be put on a wait list.9

    History and current status of Florida's Long-Term Care Waiver

    In 2011, the Florida Legislature established a statewide integrated managed care program for all covered services, including long-term care.10 The new statewide program included the “managed medical assistance (MMA) program ” for delivery of primary and acute medical assistance, and the “long-term care (“LTC”) managed care program.11 

     
    Under a managed care delivery model, the state contracts with private entities, including managed care organizations to “manage” the health care needs of their enrollees using their own network of providers. These managed care organizations (hereafter referred to as the “Plans”) act as the gatekeepers for authorization of services and referrals to network providers for covered services.

     

    After a public comment period, the Agency for Health Care Administration (AHCA) submitted two waiver applications to the Center for Medicaid and Medicare Services, (CMS), the federal agency responsible for administering Medicaid. In 2013 CMS granted approval under both to provide HCBS through the Statewide Medicaid Long -Term Care Program. (Hereafter the “LTC Waiver”).


    In 2016 AHCA requested a five (5) year renewal of both the 1915(b) and (c) waivers to continue its LTC Waiver. The 1915 (b) renewal application provided a program description, including access standards and a monitoring plan. This document also included a helpful list of the acronyms/and abbreviations used throughout the waiver, which is also included in the Appendix.12 

     

    The cover letter attached to the renewal request stated that the “purpose of the Long-term Care waiver is to provide choice of long-term home and community –based services for eligible and disabled adults in Florida as an alternative to nursing facility services for their long-term care . . . to provide incentives to serve recipients in the least restrictive setting . . .and [to] improve[] access to care and quality of care."13,14

     

    The 1915 (c) renewal application, a 233-page document, reiterated the goals. It also included detailed descriptions of the services to be offered, the case management process for developing a care plan, and other procedures designed to ensure that due process is protected.

     

    CMS approved the renewal requests, including approval of an annual enrollment cap of 62,500 for each year of the waiver.15 The waiver applications, which contain multiple terms and conditions, are posted online16 and cited throughout this Guide. Advocates should be familiar with these documents, as they provide extensive detail describing how the State will operate the Program and form the basis for the federal government’s approval of the Waiver.17

  • Section 3: Waiver Overview

    Different Agencies

    Federal law requires each state to administer its Medicaid program through a single state agency.18 The designated state agency in Florida is the Agency for Health Care Administration (AHCA).19
     

    Thus, AHCA is ultimately responsible for ensuring that the LTC Waiver complies with all aspects of federal and state law, including the promulgation of appropriate administrative rules, and development of contracts between AHCA and the Plans that accurately reflect federal and state statutes and regulations.

     

    AHCA administers the waiver in partnership with, the Department of Elder Affairs (DOEA), which maintains the statewide wait list for the LTC Waiver and assists with enrollment.20 The Department of Children and Families (DCF) is responsible for determining financial eligibility.21

    Waiver Populations

    The 2011 Florida statute establishing the statewide integrated managed care program described the populations required to enroll as including beneficiaries needing a nursing home level of care who are: 1) age 18 and older, who are eligible for Medicaid due to blindness or disability or 2) age 65 or older who are eligible for Medicaid based on age.22 Following CMS’s approval, enrollees in four existing HCBS waivers: the Aged/ Disabled Waiver, the Assisted Living Waiver, the Channeling for the Frail Elderly Waiver, and the Nursing Home Diversion Waiver were transitioned into the LTC Waiver.


    In 2017, state legislation was passed directing AHCA to consolidate three other adult HCBS waiver populations (Project AIDS Care, Traumatic Brain and Spinal Cord and Adult Cystic Fibrosis) into managed care. Pursuant to the statue, individuals from each of those waivers were transitioned into the LTC Waiver in January 2018.23

    Role of the Managed Care Plan

    As discussed more fully below, all Plans operate under the same Model Contract with AHCA which requires provision of covered services that are “medically necessary” for the individual enrollee. The case manager, the main point of contact between the enrollee, helps develop a “plan of care,” and is responsible for providing ongoing assistance in obtaining necessary services.24

  • Section 4: What Eligibility Standards Apply to the LTC Program?

    Clinical

    In order to meet clinical eligibility, applicants must require a “nursing facility level of care.25 Determining if the applicant requires nursing facility care (also referred to “the level of care determination”) is done by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program.26

    Financial

    Financial eligibility is determined by the Department of Children & Families (DCF) pursuant to SSI- Related Medicaid rules.27 If an LTC Waiver applicant is already Medicaid-eligible because he or she receives Supplemental Security Income, DCF does not need a new application.


    The 2018 income limit for HCBS waiver programs is 300% of the SSI income limit, or $2,250 per month for an individual ($750 X 300%), and $ 4,500/month for couples who are both eligible ($1,500 X 300%).28 Applicants for the LTC Waiver whose income is over this amount may still qualify by establishing an income trust that receives the person’s “excess” monthly income.29 The asset limit is $2000 for an individual and $3000 for a couple, not including certain exempted assets, such as the homestead or a vehicle.30

    Advocate Tips

    Financial eligibility is complicated, and this Guide does not attempt to address Medicaid planning for persons whose assets or income exceed the Medicaid limits, or for couples where only one spouse requires LTC Medicaid. These applicants should find either a local legal aid or elder law attorney with expertise.

  • Section 5: What is the Application Process?

    Application Steps

    Step 1 - Make an appointment to be screened for LTC Waiver wait list priority

    For most applicants, the first step is contacting the local Aging & Disability Resource Center (ADRC) or the Elder Helpline at 1-800-96-ELDER (1-800-963-5337). Florida has eleven (11) ADRCs and the contact information for the applicable office can be found at the Department of Elder Affairs website.31 Relevant contact information for each region is also included in the Appendix.


    The ADRC will either set an appointment when the applicant or the applicant’s authorized representative calls, or will send a letter scheduling a telephone appointment for the initial assessment, usually within two weeks of the initial ADRC contact.

    Advocate Tips

    • Indicate directly to the ADRC that you want to apply for the LTC Waiver program.
    • Persons with cognitive or communication related disabilities can request a “reasonable modification” such as an in-person assessment. The modification request should be made during the initial call to the ADRC and followed up with a written request.

    Step 2: The 701S Assessment and Waiver Prioritization 

    The ADRC telephonic assessment of needs uses the 701S Screening Form.32 This form gives a “priority score” that measures both the applicant’s need for assistance as well as what caregiver resources are currently available.33 

     
    The interviewer will ask for information including: if the applicant lives alone or has a caregiver; the caregiver’s health status and ability to continue to provide care; the applicant’s present health and how it compares to the prior year; how the applicant’s health may limit preferred activities; assistance needed with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)34; and health care resources available to the applicant, including access to health care and medications.35

    Advocate Tips

    Preparing for the initial call/assessment:

    1) Before the interview, review the 701S Screening Form and the training power-point provided to interviewers36


    2) Because the 701S initial assessment is an abbreviated version of the 701B comprehensive assessment, it is also helpful to review the 701D form, which provides standardized instructions for assessors completing the 701B.37

    Because the 701S form measures both the applicant’s need for assistance and the caregiver resources currently available, it is important to underscore exactly what the applicant cannot accomplish independently, be realistic about what a caregiver can actually do, and underscore any questions/concerns about the caretaker’s sustainability.

    Once the 701S form is completed, the ADRC will calculate the priority score and assign a frailty-based level or category referred to as a “rank.”38 The individual is scored using a matrix.39 An individual is prioritized for LTC waiver services based on their score and rank:

    • Rank 1: 0-15.
    • Rank 2: 16-29.
    • Rank 3: 30-39.
    • Rank 4: 40-45.
    • Rank 5: Greater than or equal to 46.
    The Medicaid rule regarding LTC prioritization specifies three (3) additional categories of individuals listed above the rank of 5 regardless of their priority score.40 Those include:
    • Rank 6: Aging Out Referral (individuals in disability programs who reach the maximum age for those programs).
    • Rank 7: Imminent Risk of Nursing Home Placement.
    • Rank 8: Adult Protective Services High Risk Referral
    Individuals are entitled to written notification after the 701S screening is completed. This written notice, which the ADRC is required by rule to send, includes:
    • The individual’s priority rank;
    • Contact information for the ADRCs;
    • Instructions for requesting an administrative fair hearing in accordance with Title 42, Code of Federal Regulations (CFR), Section 431, Subpart E;
    • Instructions for requesting a copy of the completed screening tool, which includes the priority score; and
    • Instructions for requesting a rescreening. The individual, or their authorized representative, may request a rescreening due to a significant change in condition.41
    If the individual requests a hearing, the request is made to AHCA’s Medicaid Hearing Unit.42

    Designated groups who skip Steps 1 and 2

    The Florida Legislature specified three (3) categories of individuals who are entitled to priority enrollment for home and community based services under the LTC Waiver.43 Those individuals, described below, move directly to Step 3 and do not have to participate in the 701S screening assessment or wait-list process:

    • An individual who is 18, 19, or 20 years of age who has a chronic debilitating disease or condition of one or more physiological or organ systems which generally make the individual dependent upon 24-hour-per-day medical, nursing, or health supervision or intervention.
    • A nursing facility resident who requests to transition into the community and who has resided in a Florida licensed skilled nursing facility for at least 60 consecutive days.
    • An individual who is referred by the Department of Children and Families pursuant to the Adult Protective Services Act, ss. 415.101-415.113, as high risk and who is placed in an assisted living facility temporarily funded by the Department of Children and Families.
    According to state rule, someone is considered to be at “imminent risk” if the applicant is: unable to perform self-care because of deteriorating mental or physical health condition(s); there is no capable caregiver; and placement in a nursing facility is likely within a month, or very likely within three months.44

    Advocate Tips

    If an applicant is at imminent risk of being placed in a nursing home, it is important to describe to the 701S assessor in detail how the person meets each prong of the definition.

    Step 3: Release from the waitlist and determination of clinical/financial eligibility

    Pursuant to the Florida Medicaid statute, AHCA notifies the Department of Elder Affairs of LTC waiver slot availability; CARES conducts a prerelease assessment; and DOEA then “release[s] individuals from the wait list based on the priority scoring process and prerelease assessment results.”45


    DOEA has an operational manual which details the process by which individuals are released from the wait list and proceed through the eligibility and enrollment process.46 (hereafter “EMS Manual.”)47


    Pursuant to the EMS Manual, DOEA will notify local ADRCs when waiver slots have been released, and the ADRC then contacts those individuals included in the release list.48 After confirming that the individual is still in need of long-term care services49, the ADRC sends a written notification of wait list release. This notice includes information on the enrollment process and the instructions and timeframes for completing eligibility.50

    Clinical and financial eligibility

    Following release from the wait list, two determinations are necessary: clinical and financial eligibility.51 The DOEA CARES program determines clinical eligibility52 and DCF determines financial eligibility.53

    Clinical eligibility

    Applicants must have their physician, or other licensed healthcare provider familiar with their needs, complete an AHCA Medical Certification for Medicaid LTC (also referred to as Form 5000-3008)54 within 30 days from the date of the wait list notification.55


    As soon as the ADRC receives a complete and correct Form 5000-3008, they will contact the CARES office and request a Level of Care (LOC) determination.56

     

    The CARES team will then meet with the applicant and complete a 701B comprehensive assessment.57 This assessment is administered in a face-to-face meeting by a licensed healthcare provider to ensure the applicant meets the “medical eligibility” for the LTC Waiver.58 For those applicants who meet the nursing home level of care requirement, the CARES team assigns the applicant into one of three (3) levels59:

    Level of care 1: applicants residing in or who must be placed in a nursing facility.

     

    Level of care 2: applicants at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, and who require extensive health-related care and services because of mental or physical incapacitation.

     

    Level of care 3: applicants at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, who have a limited need for health-related care and services and are mildly medically or physically incapacitated.

    Financial eligibility

    Once the Level of Care is determined, the application is forwarded to the Department of Children & Families for completion of eligibility for the LTC waiver.60 Financial and clinical eligibility determinations can, and should, proceed simultaneously.


    The applicant has 35 days from the date of wait list notification to submit the Medicaid application. A Medicaid application submitted through DCF’s online ACCESS portal triggers the financial determination.


    The ACCESS application asks for the applicant’s name, SSN, date of birth, address, phone number as well as income and assets. DCF may also require verification of the applicant’s income and assets, e.g. bank statements, pay stubs, and paperwork on asset ownership or recent sales.61

    Advocate Tips

    Do not wait until all financial eligibility verification is obtained in order to submit the ACCESS application.

    The Contract between AHCA and the Plans requires that the Plan authorize and provide services to “Medicaid Pending” enrollees. However, if DCF ultimately determines that the individual is not financially eligible, the Plan may seek reimbursement from the individual.62  
     

    The Contract also allows enrollees who lose Medicaid eligibility to continue enrollment in the Plan for 60 days, (referred to as the “SIXT period”), and the Plan is required to continue providing services during the SIXT period.63

  • Section 6: What if Application is Denied or Delayed?

    Denials or delays64 during the LTC Waiver application process can be appealed.

    Initial Assessment / Priority Rank

    First, as noted above, applicants are entitled to written notice regarding the results of the 701S screening and may appeal their priority rank and/or score. Those appeals are filed directly with the state through the Agency for Healthcare Administration’s Medicaid Hearing Unit.65

    After release from waiting list

    The EMS Manual states that the post release assessment—both the clinical assessment done by CARES and the financial assessment done by DCF—fall within DCF’s responsibility.66 In addition, the final notice of case action on LTC Waiver eligibility is generated by DCF. Thus, an appeal should be filed with the DCF hearing office.67

  • Section 7: Plan Enrollment

    Picking a plan

    An applicant who is found eligible and enrolled in the LTC Waiver must select one of the private managed care plans (“Plans”) operating in the region where the applicant resides. A list of Plans in each region is available online68 and at the local ARDC.69


    Each of Florida’s eleven regions must have at least two managed care plans to choose from for long-term care services. AHCA publishes a “Snapshot” informational brochure for both LTC managed care and for MMA managed care that sets out the Regions and the available Plans.70

     

    The enrollee should look at the Choice Counseling website at www.flmedicaidmanagedcare.com; or call 1-877-711-3662 to talk to a choice counselor. An enrollee can also request that a choice counselor meet with him or her at home.

     

    Enrollees who do not voluntarily select a Plan will be auto-assigned by AHCA. The Agency can only assign Plans that meet or exceed performance standards and must take into account several factors including: network capacity; past relationship between the recipient and the provider; and geographic accessibility.71


    After selecting a Plan (or being assigned), the Plan is required to send the enrollee a Member Handbook. The required contents of the Handbook are enumerated in the Contract between AHCA and the LTC Plans and include, e.g. information on covered services and the role of the ADRC and the Independent Consumer Support Program (ICSP). See infra at Section Fourteen.72 
     

  • Section 8: Changing Plans / Disenrolling

    Recipients may request disenrollment at any time via written or oral request to AHCA. Disenrollment for any reason is permitted within the first 120 days after enrollment.73

     

    After 120 days, recipients may change plans only for “good cause” or during the annual open enrollment period.

     

    To change their Plan, beneficiaries can speak with a choice counselor at 1-877-711-3662.
     

    "Good Cause"

    Pursuant to the Core Contract, good cause for disenrollment includes:74

    • The enrollee does not live in a region where the Plan is authorized to provide services.
    • The provider is no longer with the Plan
    • The enrollee is excluded from enrollment
    • A substantiated marketing violation has occurred. 
    • The enrollee is prevented from participating in the development of his/her treatment plan/plan of care.
    • The enrollee has an active relationship (has received services from the provider within the six months preceding the disenrollment request) with a provider who is not on the Plan’s panel but is on the panel of another Plan. 
    • The enrollee is in the wrong Plan as determined by the Agency. 
    • The Plan no longer participates in the region.
    • The state has imposed intermediate sanctions upon the Plan.
    • The enrollee needs related services to be performed concurrently, but not all related services are available within the Plan network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk.
    • The Plan does not, because of moral or religious objections, cover the service the enrollee seeks. 
    • The enrollee missed open enrollment due to a temporary loss of eligibility. 


    While the Contract currently has a more expansive list of good cause reasons than the state or federal rule, it does not include the following reason which is relevant to LTC, and which is in the federal regulation:

    • The LTC enrollee experienced a change in residential, institutional or employment supports provider because the status of the provider changed from in-network to out-of-network.75 

    Other reasons per the federal and state rules for disenrollment include: poor quality of care; lack of access to services covered under the Contract; lack of access to providers experienced in dealing with the enrollee’s health care needs. However, if one of these reasons constitutes the enrollee’s cause for requesting disenrollment she/he must first try and resolve the issue with the Plan.76

    Exemptions from the LTC Waiver

    The state allows otherwise mandated beneficiaries to request exemption on a case-by-case basis. As with a request for disenrollment (see discussion above), the enrollee should contact the enrollment broker who, in this case, would refer the request to AHCA. If the issue still cannot be resolved after working with the individual and the available LTC plans in the area, the individual will be exempt from enrollment into LTC.77

  • Section 9 - Care Planning

    Initial Contact

    Once enrolled, the Plan must conduct a face-to-face visit with the enrollee within five business days.78

    Going over the Handbook

    During the initial face-to-face visit, the plan representative provides the enrollee with the Plan’s ID card, a provider directory, and an enrollee handbook.


    The Contract specifies a number of requirements for the member handbook. Significantly, and consistent with the goal of the LTC Waiver, all handbooks are required to include the following verbatim statement:79

     

    “The purpose of the LTC program is to provide you with an array of services that meet your needs and allow you to live in the setting of your choice. This includes allowing you to live in the community for as long as you choose.”


    The Handbook is also required to explain key elements of how the LTC Waiver works, including:

    • the role of the case manager;
    • how to access a case manager and services;
    • the assessment or re-assessment process;
    • the person-centered planning process;
    • local education and consumer resources;
    • participant direction for certain services;
    • how to access information including the case file.

    Explaining grievance and appeal

    Additionally, at the initial visit the plan shall review the enrollee’s rights and responsibilities, including procedures for filing a grievance, appeal, and or Medicaid Fair Hearing.

    Conducting an assessment & developing care plan

    Finally, the plan is required to conduct a comprehensive assessment and develop the person-centered care plan of care (discussed below) at the initial meeting.80

    Person-centered Planning Process

    After years of advocacy, CMS finalized rules in 2014 detailing requirements for “person-centered” planning for all HCBS programs.81

     
    “Person-centered” planning means that the process is actually directed by the individual to the “maximum extent possible.”82


    The process is intended to identify the individual’s strengths, capacities, preferences, needs, and desired measurable outcomes. Enrollees are encouraged to make decisions about service options and identify personal goals. They must also be allowed to invite anyone of his/ her choosing to participate in the process and provide aid as needed or desired.83

    Person-centered Plan of Care

    Pursuant to this planning process, Plans are required to develop a person-centered plan of care.84 This is a written document that reflects the clinical and support needs identified through the assessment process, the person-centered goals and objectives, the services and supports (paid and unpaid) that will assist the enrollee in achieving identified goals, and the service providers.85   
     

    Additionally, the plan must reflect an enrollee's risk factors and identify measures in place to minimize them, such as individualized backup plans and strategies when needed.86  
     

    Significantly, the enrollee or enrollee’s authorized representative must indicate whether they agree or disagree with each service authorization and review and sign the plan of care at initial development, annual review, and for any changes in services.87 In addition, all individuals and providers responsible for its implementation have to sign the care plan.88   
     

    In sum, the Plan of Care (or Care Plan) is the critical written document that specifies the services and supports that are to be furnished in order to meet the enrollee’s abilities, needs and preferences, e.g. to live in her/his home.89

    Advocate Tips

    • Advocates should ensure that enrollees receive a legible copy of the Care Plan to review before signing.
    • If an enrollee (or his or her authorized representative) disagrees with any part of the care plan and efforts to resolve with the case manager are not successful, an appeal should be filed.90 

    Supplemental Assessment

    As part of the care planning process, the Plans are required to complete a written LTC Supplemental Assessment, and all completed forms should be maintained in the client’s case file.91 A sample form is included in the Appendix.)

     

    In addition to including the amount of time the enrollee can be safely left alone, the assessment must include the following with regard to natural supports:

    • The role of each natural support in the enrollee’s day-to-day life;
    • Each natural support’s day-to-day responsibilities, including an evaluation of the support’s work, school, and other schedules and responsibilities in addition to caring for the enrollee
    • Each natural support’s stress and well-being, including and medical limitation or disability the natural support may have that would limit their ability to participate in the care of an enrollee (e.g. lifting restrictions, developmental disorder, bed rest for pregnancy, etc.)
    • The willingness of the natural support to participate in the enrollee’s care.

    Advocate Tips

    If there is any concern about the sufficiency of services being authorized, a copy of the LTC Supplemental Assessment should be requested from the case manager or the Plan’s grievance and appeals coordinator.

    Role of Case Management

    Effective case management is a critical part of the LTC Waiver, and Section E of the Contract (“Care Coordination/Case Management) specifies a number of case management duties and time frames for contact with enrollees.92
      
    For example, within fourteen (14) days after the initial meeting, the Plan is responsible for following up with the enrollee to ensure that services specified in the plan of care actually started.93


    In addition, the case manager is required to meet with the enrollee, including at least every 90-day (and more frequently if there has been any significant change).94


    The case manger is also responsible for ongoing assistance, including assistance in accessing LTC Waiver services, Florida Medicaid-covered services, and other medical, social, and educational services, regardless of the payer.95

    Reassessment

    Managed Care Plans must conduct an annual reassessment of the enrollee’s plan of care to determine whether an enrollee’s service needs are being met. Reassessment may be conducted more frequently if the need arises. The Plan shall complete the reassessment using Agency-required forms and the plan-developed LTC Supplemental Assessment form.96

    Participant Directed Services

    During the care planning process, enrollees who live in their own home or the home of a family member, can choose to “self-direct” certain waiver services, including adult companion, homemaker, attendant care (private duty nursing), intermittent and skilled nursing, and personal care.


    Participants who opt to self-direct these services are then responsible for training workers, setting work schedules, and submitting timesheets to the plan.97 They do not set the pay rate, however.


    Florida’s 1915(c) waiver application reflected the State’s goals for the number of participants selecting “self-direction” as starting at 300 in Year 1 and increasing to 500 for each of the last 3 years of the Waiver.98

  • Section 10: What Services are Covered?

    The Florida Legislature has specified the minimum services that LTC Plans must provide, and the state contract requires that MCOs Plans also include four (4) additional services: adult companion care; attendant nursing care; assistive care and homemaker.99


    A complete list of the services is included in the Appendix, and each service is also briefly described in the LTC Rule.100 
     

    Out of the 23 listed services, 15 are classified as “home and community-based supportive services” (which are only available through the LTC Waiver) and 7 are considered “mixed services” (which are also provided with more restrictions by Florida’s managed medical assistance (MMA) plans.)101 Mixed services are the responsibility of the LTC Plan.102 
     

    Plans must offer all listed services. None of these services has a limit or cap, beyond the requirement that the service be “medically necessary.”

  • Section 11: When Must Covered Services by Provided?

    Medical Necessity

    In determining if a covered service must be provided to an individual beneficiary (including the amount, e.g., physical therapy twice a week), the service must be “medically necessary.” There is, however, no definition of “medical necessity” in federal law for adults, including for HCBS services. Rather, the applicable federal regulation simply provides that the service must be sufficient in “amount, duration, and scope to achieve its purpose,”103 and states have significant flexibility in setting amount, duration and scope standards.104


    As a result of litigation,105 Florida’s LTC Waiver now has two standards for determining “medical necessity”—one for HCBS services, and one for “mixed services.” The “mixed service” standard, also applies to all other services covered in the Medicaid program, e.g. hospitalization. Both standards are set forth in the boxes below and the contrast is significant.


    Under the revised rule for “Home and Community-Based Supportive Services” e.g. adult companion care, adult day care, and homemaker services, “medical necessity” is now defined more liberally to acknowledge use of services to meet functional needs and access to the community,

    Medical Necessity Definition for HCBS:

    Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;


    Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide and;


    Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.


    And, one of the following:


    Enable the enrollee to maintain or regain functional capacity; or


    Enable the enrollee to have access to the benefits of community living, to achieve person-centered goals, and to live and work in the setting of his or her choice.106

    For “mixed services” (which include all types of nursing care, personal care, and all therapies), the long-standing definition of medical necessity remains applicable.

    Florida’s Definition of Medical Necessity for “Mixed Services”107

    “Medically necessary” or “medical necessity” means that the medical or allied care, goods, or services furnished or ordered must meet the following conditions:
     

    1) Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;


    2) Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;


    3) Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;


    4) Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide and;


    5) Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.

    Other Coverage Criteria

    The LTC Waiver Rule begins with a statement of the overarching goal, i.e. that Plans “provide an array of home and community-based services that enable enrollees to live in the community and to avoid institutionalization.”108


    This goal is reflected in specific criteria for coverage, which requires that plans cover services “intended to enable the enrollee to reside in the most appropriate and least restrictive setting,”109 and in the requirement for a “Supplemental Assessment."110
     

    As previously discussed, the LTC Supplement Assessment, a key factor in deciding the array of necessary services, must quantify the amount of time an enrollee may safely be left alone and the amount of time a voluntary caregiver is willing/able to provide care. If the enrollee can never be safely left alone and the caregiver works 40 hours a week, an authorization of only 15 hours a week of direct staffing should be challenged.


    Accordingly, in addition to the requirements of the LTC Supplemental Assessment, the Contract also prevents the Plans from ignoring the limitations of an enrollee’s natural support system. Specifically, the Contract's provisions on "Service Authorizations" state that the Plan "shall not deny authorization for a service solely because a caretaker is at work or is unable to participate in the enrollee's care because of their own medical, physical or cognitive impairments."111


    The Contract also mandates that Plans “shall not deny medically necessary services required for the enrollee to safely remain in the community because of cost.”112

  • Section 12 - What Are the Standards for Access and Continued Coverage?

    Timely Access Standards

    In order to ensure that plans provide timely access to services, AHCA is required to establish network adequacy standards for the plans, e.g. the number of providers in each county.113 These requirements, along with the time standards for travel are set forth in the contract between each plan and AHCA.


    For most LTC benefits, the AHCA/LTC Plan Contract requires that Plans have at least two providers in each county.114 For those services in which the beneficiary is traveling to the provider, e.g. adult day care or therapy (physical, occupations, respiratory), the travel time maximum is 30 minutes in urban counties and 60 minutes in rural counties.115 Thus, if an individual in Miami Dade County needs physical therapy three times per week and the travel time to a network provider is an hour, the plan has violated this standard. If the issue cannot be resolved, the recipient has a basis for a good cause disenrollment. See Section, Eight, supra.


    The Core Contract (which governs both MMA and LTC plans) also requires that plans have sufficient provider contracts to ensure that medically necessary services can be provided with “reasonable promptness” as set forth in the Medicaid Statute.116
     

    The LTC Contract’s Network Adequacy Standards (Section VI) require that plans “provide authorized HCBS within the timeframes specified in Section V, Covered Services.”117 In turn, Section V requires plans to ensure services are started within fourteen (14) days after the plan of care is developed and that the plan of care is developed at the initial meeting (within 5 days of enrollment); therefore, enrollees should begin receiving medically necessary services within 19 days of enrollment.118,119

    Care Coordination and Continuity

    Florida’s LTC contract requires that the MCO have a process for “immediately reporting any unplanned gaps in service delivery.” As part of this process, the Plan must prepare a “Service Gap Contingency and Back-Up Plan” for enrollees who receive services in their home. A “gap” is the difference between the number of hours required by the care plan, and the number of hours actually provided.120


    The contingency plan must inform the enrollee (or authorized representative) of resources available, including on-call back-up service providers and the enrollee’s "informal support system” in the event of an unforeseeable gap, such as a service provider illness or transportation failure.

     
    The “informal support system" is not the “primary source” for addressing a gap, unless that is the enrollee’s choice. The MCO must ensure that gap services are provided within a three-hour time frame. The MCO must discuss the contingency plan with the enrollee, provide a copy to her/him, and ensure that the plan is updated quarterly.121


    LTC plans are also required to include “distinct procedures” in their Utilization Management Program that include “protocols for ensuring that there are not gaps in service authorization for enrollees requiring ongoing services.”122

     
    Additionally, in order to help ensure that enrollees do not experience gaps in critical LTC services, plans are required to authorize “maintenance therapies” i.e. treatments that are supportive rather than corrective and that prevent further deterioration123 for no less than six (6) months. If the service is authorized for less than six months, the decision must be “supported by objective evidence-based criteria.”124   

    Advocate Tips

    Because physicians may be unaware of this “maintenance therapy” policy and the ability to write prescriptions for up to 6 months for long-term care conditions, it can be helpful to provide the physician’s office with a copy of this contract provision.

    Finally, the Contract requires plans to provide covered services, including case management to enrollees who lose eligibility for up to sixty (60) days.125

  • Section 13: What if Services are Denied, Delayed, Reduced or Terminated?126

    Filing an AHCA Complaint

    Enrollees who are having trouble accessing services or who are encountering other problems with their LTC Plan can file an official complaint with AHCA. These complaints are reviewed and responded to by trained staff members. 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.

     

    • A complaint may be filed either online127 or by speaking with a Medicaid representative by calling toll free 1-877-254-1055.  
    • 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.  

    Grievances, Appeals, and Fair Hearings

    What is the difference between a grievance and an appeal?

    Each Plan is required to have a grievance and appeal process that complies with the federal Medicaid managed care regulations.128 The major difference between a grievance and an appeal is that an appeal should be filed when there is an “adverse benefit determination (ABD),” while a grievance would be filed if the enrollee is unhappy with the plan. For example, an enrollee could file a grievance if he or she was treated rudely.129

    Filing and resolving a grievance or appeal with the Plan

    Grievances and appeals can be filed orally or in writing; however, an oral request for an appeal must be followed with a signed appeal within 10 days (unless the request is for an expedited appeal.)130 The best practice is to file a written request with the Plan. The enrollee handbook must provide the necessary instructions and information for both grievances and appeals.131 In addition, any notice of adverse benefit determination should include instructions on how, where, and when to file an appeal. (see discussion below).


    The Plan must provide written notice acknowledging the receipt of the grievance or appeal within five business days.132  

    Expedited Appeal

    Enrollees have the right to an expedited appeal if the standard resolution “could seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain, or regain maximum function.”133

    What are the time standards for filing and resolving grievances and appeals and what notice is required?134

    Filing and resolution timeframes both for LTC and MMA plans are as follows:

    • Grievance – can be filed at any time and must be decided within 90 days.135
    • Standard appeals –filed orally or in writing within 60 days from the date of the adverse benefit determination notice and must be resolved within 30 days.136
    • Expedited appeals – file written appeal within 10 days of oral request and must be resolved within 72 hours.137

    Note that these time frames can be extended if the enrollee requests an extension. However, if the Plan requests an extension, the Plan must demonstrate to the state the need for additional time and why the extension would be in the enrollee’s best interests.

    How to ensure the continuation of benefits?

    When a beneficiary’s previously authorized services are terminated, suspended or reduced, she/he has the right to receive continued coverage of the medical services pending the outcome of an appeal and fair hearing. The importance of the right to “aid pending” for low income individuals was recognized by the United States Supreme Court in the seminal case of Goldberg v. Kelly, 397 U.S. 254, 261 (1970). Accordingly, services must be continued if all of the following occur:

    • Appeal involves termination, suspension, or reduction of previously authorized service;
    • Services were ordered by authorized provider; 
    • Period covered by original authorization not expired;
    • Enrollee timely files for continued benefits on or before ten calendar days of the plan’s notice of adverse benefit determination.138

    If the beneficiary is provided with continued coverage of the service and ultimately loses the appeal, the cost of the service can be recouped.139

    Advocate Tips

    • To ensure that services continue, the appeal must be received by the Plan within 10 calendar days of when the notice of adverse benefit determination was sent.
    • If the appeal is upheld, the fair hearing request must then be filed within 10 calendar days of when the notice of appeal resolution was sent.140
    • The request for continuation of services should always be in writing.

    Notice of Appeal Resolution

    The Plan must send a written notice of the appeal resolution that includes:

    • Results of resolution process and completion date; and if the result was not completely in favor of the enrollee, the notice must include: 
      • Information about the right to request a fair hearing and how to do so, and
      • Information on the right to continued benefits pending a final determination.141

    What is an Adverse Benefit Determination (ABD)?

    Adverse benefit determinations include:

    • Denial, reduction, suspension, termination or delay of a previously authorized service;
    • Denial or limited authorization of a requested service determination (e.g. 2 hours of speech therapy/week for 6 months were prescribed and plan approved 1 hour/week for one month); 
    • Failure to provide service in a timely manner as defined by the State;142
    • Failure of a Plan to act within required timeframes for resolution of grievance or appeal; and
    • Denial in whole or in part of the payment for a service.143

    In addition, ABDs include the denial of an enrollee’s request for an out-of-network service if the enrollee lives in a rural area and there is only one Plan.

    Is there a requirement that the Plan appeal process be exhausted before filing a fair hearing?

    As of 2017, enrollees must first exhaust the Plan’s appeal process. Thus, a fair hearing can only be requested after notice that the adverse benefit determination has been upheld (at least in part) in the Plan appeal process.144

    Are there any exceptions to exhaustion requirement?

    Yes. If the Plan does not follow the notice and timing requirements in 42 C.F.R. § 438.404(c) (described below), the enrollee is “deemed to have exhausted” the plan appeal process and can request a state fair hearing.145

    What Notice Requirements Apply?

    The Supreme Court has long recognized the importance of written notices as part of procedural due process.146 The federal Medicaid Program regulations which apply to all fair hearings (including for eligibility and non- managed care services) include detailed notice requirements.147
     

    Additionally, the 2016 federal Medicaid managed care regulations specifically linked the Plan notice requirements to an “adverse benefit determination” and set forth requirements pertaining to both the content and timing of the notice.148
     

    The notice must include the following information:

    • The ABD that has been made;
    • Reason(s) for the ABD (including the right to copies of all documents relevant to the decision free of charge);
    • Right to request an appeal, including: 
      • Information on exhausting one level of appeal
      • Right to request a state fair hearing;
    • Process for appeal;
    • Circumstances for an expedited appeal and how to request;
    • Right to have benefits continue pending resolution of the appeal, including:
      • How to request continued benefits 
      • Circumstances under which enrollee may be required to repay the costs of those services.149

    Additionally, the notice must be accessible to individuals with disabilities or limited English proficiency.150
     

    Accordingly, AHCA developed template notices that all managed care plans are required to use, including a template notice of an adverse benefit determination made by LTC Plans.151 See Appendix.

    What time standards apply to various notices?

    • If the action concerns a termination, suspension, or reduction of a benefit - written notice must be sent 10 days before the date of action.
    • If the action concerns a denial of payment - notice must be sent at time of the action-affecting claim. 
    • If the action concerns a standard service authorization decision that denies or limits services - notice must be sent within 14 days.
    • If an expedited service authorization has been requested - notice must be sent within 72 hours. 
    • If service authorization is not reached within the time frame specified in 42 C.F.R. § 438.210(d), this constitutes a denial on the date that the timeframe expired.152

    The following are examples of notices that fail to meet the notice content and time requirements. Thus, exhaustion should be deemed to have occurred and the enrollee can request a fair hearing if, e.g.:

    • Enrollee speaks Spanish and notice was only in English; (violates 42 C.F.R. § 438.10(d); see also 42 C.F.R. § 438.404 (a));
    • Notice did not clearly explain the right to continued benefits; (violates 42 C.F.R. § 438.404(b)(6));
    • Notice was not sent within 10 days of a termination, suspension or reduction of previously authorized benefits. (violates 42 C.F.R. § 438.404(c)(1)). 

    Fair Hearings

    Statutory right

    Under the federal Medicaid Act, Medicaid beneficiaries have the right to a fair hearing if a claim for medical assistance is denied or not acted on with reasonable promptness.153

    Exhaustion requirement and exceptions

    As discussed above, enrollees must first exhaust the Plan’s appeal process. Thus, a fair hearing can only be requested after the Plan issues its notice that the adverse benefit determination has been upheld.154
     

    And, as noted above, if the plan does not follow the notice and timing requirements in 42 C.F.R. § 438.404(c), the enrollee is “deemed to have exhausted” the plan appeal process and can request a state fair hearing.155

    Filing and Parties

    Medicaid appeals related to services for persons enrolled in a managed care plan are directed to AHCA.156 The Plan is the respondent, and "upon request by AHCA, the Agency may be granted party status by the Hearing Officer."157

    Hearing rights

    Enrollees have the right to:

    • Bring witnesses
    • Make legal and factual arguments in person and in writing. 
    • Present evidence, including new evidence not available at time of decision, 
    • Review medical records and case file free of charge and in advance.158

    The hearing officer can also obtain, at agency expense, a medical assessment from someone not involved in the original decision.159

    Requesting the case file

    The federal regulations and state rules both acknowledge the right of the enrollee to receive, free of charge and a reasonable time before the hearing, a complete copy of the enrollee’s case file.160 42 CFR 431.242; 59G-1.100(12), F.A.C.
     

    This should include the member notes or case notes, which are records of actions by Plan staff (including the Medical Director) related to the enrollee’s care or interactions with the enrollee and providers. The enrollee is also entitled to copies of documents or records relevant to the Plan’s adverse benefit determination.

    Advocate Tip

    Request a copy of the case file and other relevant documents, in writing when filing the appeal and the fair hearing request. If the Plan fails to respond, file an AHCA complaint or contact the Plan’s counsel directly. In the case of a fair hearing, if attempts to resolve with Plan counsel are unsuccessful, a motion to compel can be filed.

    Discovery and subpoenas

    Florida is one of the only states providing discovery in the fair hearing process, including for hearings related to managed care. AHCA's managed care fair hearing rule provides that the Florida Rules of Civil Procedure apply and the Hearing Office may issue orders to "effect the purposes of discovery and to prevent delay."161

    Relief

    The hearing officer’s Final Order should be rendered within 90 days of the requires for fair hearing, unless the time period is waived by the enrollee or extended by the hearing officer. 59G-1.100(18), F.A.C.


    Enrollees can also request corrective action retroactive to the date of the error, including payments made by the enrollee to cover services that were improperly terminated.162

    Advocate Tip

    In addition to requesting the enrollee’s case file, helpful discovery can include:
    1) Requests for production of documents
    2) Interrogatories
    3) Requests for Admissions
    4) Depositions163

  • Section 14: Other Advocate / Consumer Resources

    As part of the LTC Waiver, Florida has established the Independent Consumer Safety Program (ICSP). The ICSP coordinates efforts between the Florida Department of Elder Affairs, the Statewide Long-term Care Ombudsman Program (LTCOP), local ADRCs and AHCA. The ICSP uses staff from LTCOP, DOEA and ADRCs to help enrollees understand and resolve service, coverage, and access complaints.164


    Pursuant to the Contract, Plans are required to have an enrollee advisory committee that meets at least twice a year to consider issues and “obtain periodic feedback” on any identified problems and suggestions for improvement. Plans submit minutes of these advisory committee meeting, along with the plan’s response to identified concerns to AHCA.165

    Advocate Tips

    Obtain copies of the advisory committee materials for the LTC Plans in your region and, depending on the information received, discuss appropriate strategic responses with your local ADRC and ICSP staff.

  • Section 15: Summary of Relevant Authority

    The multiple authorities related to Florida’s LTC program (and cited in the endnotes) are summarized below. These authorities include federal and state statutes and regulations (rules); contractual provisions between AHCA and the plans, the Waivers Requests and Approval between the state and federal government; and relevant case law, including Settlement Agreements or Orders.

    Federal Statutes:

    42 U.S.C. § 1396n.

    Federal Regulations:

    The 2016 federal Medicaid Managed Care regulations at 42 C.F.R. part 438, a significant regulatory overhaul, increased transparency and modernized Medicaid’s managed care programs. Also, for the first time, CMS included specific provision pertaining to LTSS and defined LTSS for the purposes of managed care.166


    Other relevant federal regulations include 42 C.F.R. § 435.217 (describing individuals who are eligible for home and community –based services), 42 C.F.R. § 440.180 (providing a description of and requirements for HCBS); and 42 C.F.R. § 441.301, et seq., (setting forth the requirements for providing HCBS through a waiver, including the requirements for a “person-centered plan and process.”)

    Florida Statutes

    In 2011, the Florida Legislature created Part IV of Chapter 409, Florida Statutes directing the Agency to create the Statewide Medicaid Managed Care (SMMC) program. The SMMC program has two key components: the Managed Medical Assistance program (MMA) and the Long-Term Care Program (which includes the LTC Waiver). Relevant sections of the Florida Statutes include Fla. Stat. 409.978- 409.985.

    Florida Administrative Rules:

    The state’s relevant administrative rules include the Rule pertaining to screening and wait list prioritization and release, Fla. Admin. Code Rule (or F.A.C.) 59G-4.193 and 59G-4.192, incorporating by reference the Florida Statewide Medicaid Managed Care Long-term Care Program Coverage Policy, March 2017.


    Also relevant are the state rules for plan disenrollment F.A.C. 59G-8.600; the AHCA managed care fair hearings rules described at 59G-1.100, and the DCF income eligibility-related rules at F.A.C. 65A-1.710 et seq.

    AHCA’s Model Contract:

    The Agency for Health Care Administration’s (AHCA) has a Model Contract, which governs all SMMC plans – both MMA and LTC. Relevant subparts include:

    • Attachment II re: Core Contract Provisions, February 1, 2018;
    • Attachment II, Exhibit II-B Feb_1_2018.pdf. 

    Please note: there will be new LTC contracts and LTC program changes beginning in December 2018.167

    Waiver Applications and Approvals

    AHCA’s LTC Waiver applications (both original and renewal) set forth in detail all aspects of how HCBS will be provided, and were approved by CMS.

    Department of Elder Affairs:

    The DOEA “Statewide Medicaid Managed Care Long-term Care Program Enrollment Management System Procedures Manual", provides a detailed description of the process by which individuals are released from the wait list and the eligibility and enrollment process.

  • Appendix A: Abbreviations

    CMS Network

    Children's Medical Services Network

    DCF

    Department of Children and Families

    DOH

    Department of Health

    CMS

    Centers for Medicare and Mediaid Services

    FS

    Florida Statutes

    FFS

    Fee-for-Services

    HMO

    Health Maintenance Organization

    LTC

    Long-term Care

    MMA

    Managed Medical Assistance

    MCO

    Managed Care Organization

    PAHP

    Prepaid Ambulatory Health Plan

    PCCM

    Primary Care Case Management

    PCP

    Primary Care Provider

    PDHP

    Prepaid Dental Health Provider

    PIHP

    Prepaid Inpatient Health Plan

    PMHP

    Prepaid Mental Health Program

    PSN

    Provider Services Network

    STC

    Special Terms and Condition

    SSI

    Supplemental Security Income

    TANF

    Temporary Assistance for Needy Families

    The Act

    Social Security Act

    The Agency

    Agency for Health Care Adminstration

  • Appendix B: Services

    LTC Program Minimum Covered Services

    Adult Companion Care

    Adult day health care

    Assisted living

    Assistive care services

    Attendant nursing care

    Behavioral management

    Care coordination / Case management

    Caregiver training

    Home accessibility adaptation

    Home-delivered meals

    Homemaker

    Hospice

    Intermittent and skilled nursing

    Medical equpment and supplies

    Medication administration

    Medication management

    Nursing facility

    Nutritional assessment / risk reduction

    Personal care

    Personal emergency response system

    Respite care

    Therapies: occupational, physical, respiratory and speech

    Transportation, Non-emergency

  • Appendix C: Care Plan

    What is included in the Person-Centered Plan of Care?

    Every enrollee's person-centered plan of care must include:

    • Enrollee's name and Florida Medicaid identification number
    • Plan of care effective date
    • Plan of care review date (at least every 90 days)
    • The enrollee's personal goals
    • The enrollee's strengths and preferences
    • Routine medical services needed, including how much, how often, and who is providing the service(s)
    • Availability of natural supports to assist in the enrollee's care
    • Long-term care waiver services, including how much, how often, and who is providing the service(s)
    • Each service authorization start and end date (if applicable)
    • A complete list of services and supports to be provided, no matter who is paying
    • Medication oversight strategies
    • Current living arrangement and choice of living arrangement
    • If the enrollee's current living arrangement and choice of living arrangement differ, a goal toward achieving the chosen living arrangement and barriers to be overcome in achieving the goal
    • Records of enrollees' advance directives, health care powers of attorney, do not resuscitate orders, or a legally appointed guardian
    • If the enrollee resides in an assisted living facility (ALF), services provided by the ALF, including how much and how often the ALF provides those services
    • Identification of any existing plans of care and service providers and assessment of the adequacy of existing services
    • Identification of who is responsible for monitoring the plan of care
    • Case manager's signature
    • The word-for-word written statement before the enrollee signature field as follows:
      • "I have received and read the plan of care. I understand that I have the right to file an appeal or fair hearing if my services have been denied, reduced, terminated, or suspended.", and
    • Enrollee or enrollee's authorized representative's signature and date

    To learn more about the Statewide Medicaid Managed Care Program: Visit the Agency's SMMC Program website at: www.ahca.myflorida.com/SMMC.

  • Appendix D: Supplemental Assessment Form

  • Appendix E: Template Notice

    Editable template (Word document)

  • Endnotes

    Section 1 Endnotes

    1 Reinhard et al, Picking Up The Pace of Change: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, Long-Term Services and Supports State Scorecard 2017 Edition, at 5. LTSS scorecard (LTSS State Scorecard: 2017 Ed. AARP et al.) at 5 (about 52% of will at some point develop a severe disability that will require LTSS.)
     
    2 Fla. Stat § 409.979 (1); see also § 1915(c) of the Social Security Act authorizing state Medicaid programs to provide home and community-based services, including services that are not strictly medical in nature, for individuals who would otherwise need care in a nursing home or other institution, are authorized under. 42 U.S.C. § 1396n(c); 42 C.F.R. § 440.180(b).
     
    3 Fla. Stat § 409.979 (3).
     
  • Section 2 Endnotes

    4 § 1915(c) of the Social Security Act, 42 U.S.C. §1396n(c).
     
    5 Fla. Stat. §409.979(1)(a)1.
     
    6 42 U.S.C. § 1396a(a)(1), (10)(B),(10)(C)(i).
     
    7 42 U.S.C. § 1396a(a)(23).
     
    8 42 U.S.C. §1396n(c)(9).
     
    9 Nursing home services, unlike HCBS, are mandatory under federal and state Medicaid statute. 42 U.S.C. § 1396a(a)(10)(A)(i) Fla. Stat. §409.905(8).
     
    10 Fla. Stat. §409.964.
     
    11 Id.
     
     
    13 Fla. Stat. §, 409.978 see also
     
     
     
     
    17 Unlike the Section 1115 Waiver authorizing Florida to implement a statewide mandatory managed care system for Medicaid’s general medical services, however, CMS' approval of the managed care program for long-term services and supports does not contain any specific agreement between CMS and the State specifying how the state is required to administer the waiver. See https://www.floridahealthjustice.org/medicaid-guide.html at 24, re August 3, 2017, CMS new Special Terms and Conditions (STCs) pertaining to the 1115 Waiver’s approval period from August 2017 through June 2022.

     
  • Section 3 Endnotes

    18 42 U.S.C. §1396a(a)(5); 42 C.F.R. § 431.10.
     
    19 Fla. Stat. § 409.901(2).
     
    20 See Fla. Stat. § 409.979 (3) for description of DOEA responsibilities in the LTC Waiver; http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(b)_LTC_Waiver.pdf at 4.
     
    21 Fla. Stat. § 409.902(1).
     
     
    23 Fla. Stat. § 409.979(2)(a); see also http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/EXHIBIT_II-B_Long_term_Care_(LTC)_Managed_Care_Program_Feb_1_2018.pdf at 3-4. (hereafter “AHCA- LTC.MCO Contract.” ), listing populations groups for whom enrollment is mandatory or excluded. Note: this 2018 Contract includes Adults with Cystic Fibrosis (not PAC or BSCI); the Contract includes dual eligible as a “mandatory population” but the 1915(b) waiver application does not. Compare, http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(b)_LTC_Waiver.pdf at 10. The 1915c application does not reflect the higher enrollment cap given inclusion of the three new waiver populations as of 7-13-18.
     
    24 AHCA-LTC.MCO Contract.
  • Section 4 Endnotes

    25 Fla. Stat § 409.985 (3); Fla. Admin. Code R. 59G-4.192, incorporating by reference the Florida Medicaid Statewide Medicaid Managed Care Long-term Care Program Coverage Policy, March 2017, (hereafter the LTC Waiver Rule), March 2017 at 3.
     

    26 Fla. Stat. § 409.985 (1)(3).
     

    27 Fla. Stat. § 409.902(1); Fla. Admin Code R. 65A-1.712(1)(f); Fla. Admin Code R. 65A-1.713(1)(e).


    28 Fla. Admin Code R. 65A-1.716(5)(b).
     

    29 Fla. Admin. Code R. 65A-1.713(1)(e) noting that establishment to an income trust for purposes of qualifying for HCBS must comply with the requirements set forth in Fla. Admin Code R. 65A-1.702(15).
     

    30 Fla. Admin Code R. 65A-1.716(5)(a); see also http://www.dcf.state.fl.us/programs/access/docs/esspolicymanual/a_09.pdf.

  • Section 5 Endnotes

    31 http://elderaffairs.state.fl.us./doea/arc.php - arclist.
      

    32 http://elderaffairs.state.fl.us/doea/forms/701S_Screening_Form.pdf
     

    33 Fla. Stat. § 409.979(3)(a), Fla. Admin. Code R. 59G-4.193(3)(a).
      

    34 See LTC Waiver Rule at 1-2; Sections 1.3.1; 1.3.9 defining ADLs as including, e.g. bathing, dressing, eating, toileting transferring maintaining continence and IADLs as including those activities necessary to allowing the individual to function independently, e.g. grocery shopping, laundry, light paperwork, money management.
      

    35 Id., see also http://elderaffairs.state.fl.us/doea/notices/Jan13/12-17%20FINAL%20Priority%20Score%20Training.pptx
     

    36 http://elderaffairs.state.fl.us/doea/public_traning/SMMLTCP/701S%20Training%20-%20Storyline%20output/story_html5.html.
      

    37 http://elderaffairs.state.fl.us/doea/forms/701D_Assessment_Instructions.pdf
      

    38 Fla. Admin. Code R. 59G-4.193(3)
     

    39 http://elderaffairs.state.fl.us/doea/SMMCLTC/2014_Priority_Score_Calculation.pdf
      

    40 Fla. Admin. Code Rule 59G-4.193(3)(b).
      

    41 Fla. Admin. Code Rule 59G-4.193(3)(d)5.
      

    42 Fla. Stat. § 409.285(2).
      

    43 Fla. Stat. § 409.979(f).
      

    44 Fla. Admin. Code R. 59G-4.193(2)(d).
      

    45 Fla. Stat. § 409.979(3)(d), see also the DOEA “Statewide Medicaid Managed Care Long-term Care Program Enrollment Management System Procedures Manual", for a detailed description of the process by which individuals are released from the wait list and the eligibility and enrollment process. The most recent Manual on-line is from 2014. http://elderaffairs.state.fl.us/doea/notices/Jan14/SMMC%20LTC%20EMS%20Procedures%20March%202014.pdf. Pursuant to a public records request, the authors of this Guide are aware of an updated and expanded Enrollment Management System (EMS) Procedures Manual currently in use dated October 2016. This Manual (cover page watermarked “DRAFT”) is cited throughout this Guide and is available on the FLAdvocate website: https://www.fladvocate.org/healthandsenior. (Hereafter “EMS Manual”)


    46 EMS Manual.
     

    47 Id. at 4.
      

    48 Id. at 9; see also Id at 1, noting that because there are a limited number of Medicaid recipients who may be enrolled, the frequency of releases from the waitlist varies.
      

    49 Id. at 9-10
      

    50 Id. at 11.
      

    51 Fla. Admin. Code R. 59G-4.1939(g), see also, EMS Manual at 4.
      

    52 Fla. Stat. § 409.985, Fla. Admin. Code R. 59G-4.180, 59G-4.290.
      

    53 Fla. Stat. § 409.902(2), Fla. Admin. Code R. 65A-1.205.
      

    54 Fla. Admin. Code R. 59G-1.045(4), see also, http://elderaffairs.state.fl.us/doea/cares/Medical_Cert_for_Long_Term_Care_5000_3008.pdf.
      

    55 EMS Manual at 11.
       

    56 Id. at 17-18.
      

    57 Fla. Admin. Code R. 59G-4.193(g); Fla. Admin. Code R. 58A-(1)(b).
      

    58 LTC Waiver Rule at Section 1.3.5; see also, http://elderaffairs.state.fl.us/doea/forms/701B_Comprehensive_Assessment.pdf
      

    59 Fla. Stat. § 409.985(3).
      

    60 EMS Manual at 18.
      

    61 Florida Department of Children and Families, Program Policy Manual, (Mar. 20, 2018), http://www.myflfamilies.com/service-programs/access-florida-food-medical-assistance-cashprogram-policy-manual. at §§ 1640.0000, 1840.0000.
      

    62 http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/EXHIBIT_II-B_Long_term_Care_(LTC)_Managed_Care_Program_Feb_1_2018.pdf at 5. (hereafter “AHCA- LTC.MCO Contract”)
      

    63 AHCA- LTC.MCO Contract at 6.

  • Section 6 Endnotes

    64 Fla. Admin. Code R. 65A-1.205(1)(b); 42 C.F.R. § 435.911(a)(1).


    65 Fla. Admin. Code R. 59G-4.193(3)(d)(3); Fla. Stat. § 409.285(2).


    66 EMS Manual at 4, see also Fla. Stat. § 409.902(1). Note also: if the DCF denial was due to “failure to submit financial documentation,” requesting a hearing will allow the opportunity to either demonstrate that documentation was provided or allow additional time to find the requested documents.; and in such cases a hearing may not be necessary.
      

    67 Appeal Hearings Section,1317 Winewood Blvd.Building 5, Room 255,Tallahassee, FL 32399-0700,Phone 850-488-1429 | Fax 850-487-0662, appeal.hearings@myflfamilies.com.

  • Section 7 Endnotes

  • Section 8 Endnotes

    73 Notably, Florida’s contract provides for a larger time frame (120 days) than the amount required under federal law (90 days). Compare http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/Attachment_II_Core_Contract_Provisions_Feb_1_2018.pdf (hereafter “Core Contract” at 53 with 42 C.F.R. 438.56(2)(c)(i).
     

    74 Core Contract at 52-53, containing a more expansive list of good cause reasons than the state rule, currently under rule development as of May 2018. Fla. Admin. Code 59G-8.600; see also 42 C.F.R. § 438.56.


    75 42 C.F.R. § 438.56(d)(2)(iv).


    76 Fla. Stat. § 409.969(2), providing that “the Agency may require a recipient to use the plan’s grievance process before the agency’s determination of good cause…” the Agency has implemented this requirement in the rule, see Fla. Admin. Code R. 59G-8.600(b). see also, http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(b)_LTC_Waiver.pdf at 33; 42 C.F.R. § 438.56.
     

    77 http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(b)_LTC_Waiver.pdf at 32-33.

  • Section 9 Endnotes

    78 AHCA –LTC.MCO Contract at 29.


    79 Id. 7.


    80 AHCA-LTC.MCO Contract at 29.


    81 See generally, Home and Community-Based Setting Requirements for Community First Choice and Home and Community-Bases Services (HCBS), 79 Fed. Reg. 2948, 303-31 (Jan 16, 2014)(codified at 42 C.F.R. § 441.301(c).
      

    82 AHCA –LTC.MCO Contract at 32.
      

    83 42 C.F.R. § 441.301(c)(1); AHCA –LTC.MCO Contract at 32.
      

    84 42 C.F.R. § 441.301(c)(2).
      

    85 42 C.F.R. § 441.301(c)(2); AHCA-LTC.MCO Contract at. 33-4., see also, https://ahca.myflorida.com/medicaid/statewide_mc/pdf/LTC/LTCSnapshot_CaseMngmtPersonCenteredCarePlanning_061917.pdf.
      

    86 42 CFR § 441.301(C)(2)(vi).
      

    87 AHCA-LTC.MCO Contract at 34; see also 42 C.F.R. § 441.301(c)(2)(ix); 42 C.F.R. 441.301(c)(3).
      

    88 42 C.F.R. § 441.301(c)(2)(ix); The requirement that providers responsible for implementing care plan sign the plan is included in the federal regulation, but does not appear in the current Contract. The Contract requires that the primary care provider be sent a copy of the plan of care and advised in writing who to contact with questions regarding adequacy. AHCA-LTC.MCO Contract at 33-34, Section V.E. 3.c.
      

    89 42 CFR § 441.301(C)(2), AHCA-LTC.MCO Contract at 33.
        

    90 Language regarding the right to written notice and appeal of the Plan of Care per se is not entirely consistent vis a viz the Rule, the Contract and the 1915c application. The Contact requires that the Plan of Care include indication by the enrollee or the enrollee’s representative that they agree or disagree with each service authorization and review and sign the plan. Contract at 34, Section V.E.3.c.(5). The LTC Rule requires that the Plan of Care be reviewed with the enrollee and include a statement preceding the enrollee’s signature attesting that the plan of care has been discussed with and agreed to by the enrollee, and the enrollee understands he/she has the right to request a Fair Hearing if services are denied or reduced,“. R. at pg.9, Sec 6.2.2. The Florida’s 1915(c) Waiver application unambiguously provides for the right to written notice and an appeal if the enrollee wishes to challenge any part of the care plan. “If the enrollee disagrees with the assessment and/or authorization of placement/services (including the amount and/or frequency of a service), the case manager must provide the participant with a written notice of action that explains the enrollee’s right to file an appeal. The case manager assists the enrollee with filing for an appeal.” https://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(c)_LTC_Waiver.pdf, July 1, 2016, (hereafter “1915(c) Waiver Application”) at 151. (emphasis added).
      

    91 LTC Waiver Rule at 8, Section 6.2.1.
       

    92 AHCA- LTC .MCO Contract at 28-35. see also 1915(c) Waiver Application at 151-5; C.F.R. . § 438.208.
      

    93 AHCA- LTC.MCO Contract at 30.
      

    94 AHCA- LTC.MCO Contract at 30.
         

    95 AHCA- LTC.MCO Contract at 22, 28-30, see also, https://ahca.myflorida.com/medicaid/statewide_mc/pdf/LTC/LTCSnapshot_CaseMngmtPersonCenteredCarePlanning_061917.pdf.
      

    96 AHCA-LTC.MCO Contract at 33; LTC Waiver Rule at 8 , Sec. 6.2.1. See Appendix for sample Supplemental Assessment Form.
      

    97 Application for 1915(c) HCBS Waiver: FL.0962.R01.00 - Jul 01, 2016 pg. 174
      

    98 Application for 1915(c) HCBS Waiver: FL.0962.R01.00 - Jul 01, 2016 pg. 181.

  • Section 10 Endnotes

    99 Fla. Stat. § 409.98, AHCA-LTC.MCO Contract at 13-4, 43-45.

     
    100 LTC Waiver Rule at 4-8; Note respiratory services were deleted in recent 1915c application at 83-4 but still in contract and statute.


    101 LTC Waiver Rule at 3, sec 1.3.15.


    102 Id.

  • Section 11 Endnotes

    103 42 C.F.R. § 440.230.


    104 See Alexander v. Choate, 469 U.S. 287 (1985)(holding that Tennessee could “reasonably” limit coverage of inpatient hospital days per year to 11): Curtis v. Taylor, 648 F. 2d 946 (5th circ. 1980) (holding that Florida’s rule limiting physician visits to 3/month did not violate federal Medicaid law.)
      

    105 Florida changed the definition rule for LTC supportive services following settlement of a statewide class action, Parrales et al. v. Dudek/Senior, N.D. F. 4:15-cv-424-RH/CAS, brought on behalf Plaintiffs enrolled in the LTC waiver who were unable to obtain necessary services. Settlement Agreement is available on the FLAdvocate Health Law website. https://www.fladvocate.org/healthandsenior/.
      

    106 Fla. Admin. Code R. 59G-4.192, incorporating by reference the “Florida Medicaid Statewide Medicaid Managed Care Long-term Care Program Coverage Policy, March 2017, (hereafter the LTC Waiver Rule) at Section 1.3.5;
      

    107 Fla. Admin. Code R. 59G-1.010, Definitions Policy, section 2.83 at 7.
      

    108 LTC Waiver Rule at 1, § 1.1.


    109 LTC Waiver Rule at 4, §§ 4.2.


    110 LTC Waiver Rule at 8, § 6.2.1.


    111 AHCA-LTC.MCO Contract at 13, 57, §§ G. 2. ,F.


    112 Id.

  • Section 12 Endnotes

    113 Fla. Stat. §§ 409.982(4); see also 42 C.F.R . §438.68.


    114 AHCA- LTC Contract at 37, 43-45.


    115 http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/EXHIBIT_II-B_Long_term_Care_(LTC)_Managed_Care_Program_Feb_1_2018.pdf. at 43-45. See also, 42 CFR 438.206; http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/Final_1915(b)_LTC_Waiver.pdf at 16


    116 The Core Contract cites to the “reasonable promptness requirement in the federal Medicaid statute at 42 U.S.C. 1396a(a)(8). Contract at 103. However, in contrast to the time standards for determining eligibility (45 days for eligibility not dependent upon disability determination; 90 days for determination based on disability), the federal law does not provide numeric standards for what constitutes “reasonable promptness” for services. Thus, disputes have arisen over what is “reasonably prompt” for different services. See, e.g. Doe 1-3 ex rel. Doe Sr. 1-13 v. Chiles, 136 F. 3d 709(11th Circ. 1998)(finding reasonable promptness provision at 1396a(a)(8) enforceable and requiring state to establish reasonable waiting list time, not to exceed 90 days for individuals eligible for IXCF/MR care.)


    117 AHCA-LTC.MCO Contract at 39. Section VI. A. 1. K.


    118 AHCA-LTC.MCO Contract at 29-30.


    119 Neither the AHCA contract with LTC plans nor the 1915(b) Waiver Request specify a time standard for obtaining a service (appointment.) This is in contrast to the MMA plan contracts, which have time standards for accessing appointments, e.g. “sick care” within one week of request. See, AHCA-MMA.MCO Contract, http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/EXHIBIT_II-A_MMA_Managed_Medical_Assistance_(MMA)_Program_Feb_1_2018.pdf., at 56-62.


    120 AHCA-LTC.MCO Contract at 22, see also 2016 federal regulations which were broadened to ensure that enrollees have access to ongoing sources of all appropriate care, including LTSS. 42 C.F.R. 438.208 (b),. Contract at 22, see also 2016 federal regulations which were broadened to ensure that enrollees have access to ongoing sources of all appropriate care, including LTSS. 42 C.F.R. 438.208 (b),


    121 AHCA-LTC.MCO Contract at 23-24.


    122 AHCA-LTC.MCO Contract at 55.


    123 LTC Waiver Rule at 2, Section 1.3.12.


    124 AHCA-LTC.MCO Contract at 57.


    125 AHCA-LTC.MCO Contract at 26.

  • Section 13 Endnotes

    126 Grievance, appeals, and fair hearings are the same for LTC as for the state's managed medical assistance (MMA) plans, Core Contract at 70-84, Section IV.


    127 https://ahca.myflorida.com/Medicaid/complaints/.


    128 42 C.F.R. §§438.228; 438.56(d)(5); 59G-8.600(3)(b)


    129 42 CFR § 438.400(b); Fla. Admin. Code 59G-1.100(2)(b) (definition of “grievance”)


    130 Core Contract, Attachment II, Exhibit II Core Contract Provisions at 87, Section IV, C. 5. B. (2); see also 42 C.F.R. § 438.406(b)(3).


    131 42 C.F.R. § 438.406.


    132 Core Contract at 86, Section IV.C.4.b.; see also, 42 C.F.R. § 438.406 (b)(1).


    133 42 C.F.R. § 438.410; Model Contract, Attachment II, Exhibit II Core Contract Provisions at 88, Section IV.C.5.m.


    134 Core Contract Section IV C. 5,6; 42 C.F.R. § 438.408.


    135 Core Contract, at 87, Section IV. C. 4.d.


    136 Id. at 87, Section IV. C. 5.b.(1).


    137 Id. at 87, Section IV. C. 5.m.


    138 Core Contract at 91, Section IV. C.6.i. 42 C.F.R. § 438.420.


    139 Core Contract at 88, Section IV.C.5.h. (the plan may require the enrollee to pay for the cost of benefits if the Medicaid fair hearing upholds the Plan’s appeal resolution 91, Section IV. C.5.h; Section IV. C.6.k. (same); see also 42 C.F.R. § 438.420(d).


    140 42 CFR 438.420(c).


    141 42 C.F.R. § 438.408(e); Core Contract at 89 Section IV. C. 6.n.


    142 However, as noted above, see n. 117 supra, neither the AHCA contract with LTC plans nor the 1915(b) waiver request specify a time standard for obtaining a service (appointment),


    143 42 C.F.R. § 438.400(b); Fla. Admin. Code 59G-1.100(2)(b) (definition of “adverse benefit determination”).


    144 42 C.F.R. § 438.402; Fla. Admin. Code R. 59G-1.100 (3)(b)1; Core Contract at 86 Section IV, (C)(4)(a).


    145 42 C.F.R. § 438.402 (c)(1)(A); 42 C.F.R. § 438.408(c)(3); Fla. Admin. Code R. 59G-1.100 (3)(b)2-3.


    146 Goldberg v. Kelly, 397 U.S. 254 (1970).


    147 42 C.F.R. § 431.210 et seq.


    148 42 C.F.R § 438.404.


    149 Core Contract at 89 requires that the plan use the template notice provided by AHCA. See Appendix for Template Notice.


    150 42 C.F.R § 438.10, Fla. Admin. Code R. 59G-1.100(2)(t); http://www.fdhc.state.fl.us/medicaid/statewide_mc/smmc_plan_comunications_archive.shtml, linking to a February 24 Policy Transmittal requiring that plans use a template notice. (available on the FLAdvocate Health Law website. https://www.fladvocate.org/healthandsenior/).


    151 Statewide Medicaid Managed Care (SMMC) Policy Transmittal, 2.24.17, Policy Transmittal: 17:08 at http://ahca.myflorida.com/medicaid/statewide_mc/smmc_plan_comunications_archive.shtml. A copy of the template LTC notice of adverse benefit determination is in the Appendix. See also Contract at 58 I, j


    152 42 C.F.R. § 438.404(c).


    153 42 U.S.C. § 1396a(a)(3).


    154 42 C.F.R. § 438.402; Fla. Admin. Code R. 59G-1.100 (3)(b)1; Model Contract, SMMC, at 86 Section IV, (C)(4)(a).


    155 42 C.F.R. § 438.402 (c)(1)(A); 42 C.F.R. § 438.408(c)(3); Fla. Admin. Code R. 59G-1.100 (3)(b)2-3.


    156 Fla. Stat. § 409.285(2).

     

    157 Fla. Admin. Code R. 59G-1.100 (4).


    158 42 C.F.R. § 438.406(b)(4)(5); compare Model Contract, Attachment II, Exhibit II Core Contract Provisions, Section IV.C. 5.d. at 87. (contract includes all of the provisions in federal regulation except the right to review of medical records and file free of charge).


    159 42 CFR 431.240(b); Fla. Admin. Code R 59G-1.100(17)(n),


    160 42 CFR 431.242; Fla. Admin. Code R 59G-1.100(12),


    161 Fla. Admin. Code R. 59G-1.100 (13).


    162 42 C.F.R. § 431.246; Rule 59G-1.100(18)(f). See also, See Kurnik v. Department of Health and Rehabilitative Services, 661 So. 2d 914 (Fla. Dist. Ct. App. 1995) French v. Dep't of Children & Families, 920 So. 2d 671 (Fla. 1st DCA 2006).


    163 Sample discovery is available on the FLAdvocate Health Law website. https://www.fladvocate.org/healthandsenior/.

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