Assisted Living Waiver Services

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO.: RULE TITLE:
59G-13.050: Assisted Living Waiver Services

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 37 No. 27, July 8, 2011 issue of the Florida Administrative Weekly.

The following change was made to the Notice of Proposed Rule.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule A SERC has not been prepared by the Agency. A checklist was prepared by the Agency to determine the need for a SERC. Also, based on this information at the time of the analysis and pursuant to Section 120.541, F.S., the rule will not require legislative ratification.

Any person who wishes to provide information regarding the statement of estimated regulatory costs or to provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

The following changes have been made to the Florida Medicaid Assisted Living Waiver Services Coverage and Limitations Handbook, March 2011.

Page 1-10 Provider Responsibilities: Personal Needs Allowance (PNA).

Paragraph is changed to read:

All recipients of AL waiver services must be allowed to keep from their personal income an amount equal to the personal needs allowance (PNA) under the Optional State Supplementation (OSS) Program (Rule 65A-2.036, F.A.C.). The PNA must be available to the resident by the tenth day of each month. The facility may assist the resident in managing these personal funds, but may not restrict how the resident chooses to spend the PNA funds.

Page 2-2 Service Requirements: Determination of Medicaid Eligibility.

First paragraph is changed to read:

Individuals not already receiving Optional State Supplementation (OSS) or Medicaid benefits must be referred to the local Department of Children and Families (DCF) Automated Community Connection to Economic Self-Sufficiency (ACCESS) office or online at www.myflorida.dcf.state.fl.us/ess to apply for Medicaid coverage.

Seventh paragraph is changed to read:

Note: Information regarding Medicaid eligibility is available on the Internet at: http://www.dcf.state.fl.us/programs/access/

Page 2-5 Service Requirements.

Comprehensive Client Assessment

Fourth paragraph is changed to read:

Note: See Appendix A in this handbook for a copy of the Department of Elder Affairs Assessment Instrument, DOEA Form 701B. This form is available from DOEA’s Web site at: http://elderaffairs.state.fl.us/english/pubs/pubs/doea701b_sep08.pdf. It is incorporated by reference in Rule 59G-13.030, F.A.C. The Department of Children and Families Assessment Instrument, DCF Form CF-AA 3019, is available from DCF’s website: http://dcf.state.fl.us/dcfforms/Search/DCFFormSearch.aspx. It is incorporated by reference in Rule 59G-13.030, F.A.C.

Request for Level of Care

Second paragraph is changed to read:

Note: See Appendix B in this handbook for a copy of the Medical Certification for Nursing Facility/Home and Community Based Services Form (MCNF/HCBS), AHCA-Med Serv Form 3008. The form is available on the DOEA Web site at: http://elderaffairs.state.fl.us/english/cares.php. It is incorporated by reference in Rule 59G-13.030, F.A.C.

Page 2-6 Service Requirements.

Informed Consent Form

Second paragraph is changed to read:

Note: See Appendix C for a copy of the Informed Consent Form, AHCA Med-Serv Form 2040 in English and Spanish. The form is available on the DOEA website at: http://elderaffairs.state.fl.us/english/cares.php. It is incorporated by reference in Rule 59G-13.030, F.A.C.

Level of Care Determination

Third paragraph is changed to read:

The LOC must be determined annually by CARES for all recipients and documented in the beneficiary’s case record. The case manager is required to track LOC reassessment in conjunction with the annual 701B reassessments to ensure that timely evaluations are conducted.

Page 2-9 Service Requirements: Availability of Other Coverage Sources and Services.

First paragraph is changed to read:

When a service must be purchased, services available under the Medicaid state plan must be used before accessing services through the waiver. The waiver cannot supplant or replace a service that is available through the Medicaid state plan. It is a federal requirement to access state plan coverage before the provision of waiver services.

However, this does not affect the services provided by the ALF to recipients under the AL’s “assisted living services.” These services are part of the waiver program, reimbursed to the facility and not accessed through state plan.

Page 2-11 Case Management Requirements: Visit Requirements.

First bullet is changed to read:

Maintain, at a minimum, face-to-face contact with the recipient to verify satisfaction and receipt of services.

Page 2-12 Case Management Documentation: Recipient Case Records.

Last paragraph is changed to read:

Note: See Appendix E for a copy of the Cooperative Agreement for a Hospice and Medicaid Waiver Enrolled Recipient, AHCA Form 5000-30. It is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Provider Support, and then Medicaid Forms. It is incorporated by reference in Rule 59G-13.030, F.A.C.

Page 2-15 Plan of Care: Plan of Care Document.

First bullet is changed to read:

Client name and Medicaid identification number;

Second bullet is changed to read:

Case management agency name and Medicaid provider identification number;

Fourth bullet is changed to read:

Types, frequency and duration of planned DOEA and non-DOEA services;

Page 2-16 Plan of Care: Plan of Care Development.

Second paragraph is changed to read:

The plan of care must specify all of the client’s services. The plan of care should also include a client’s individual goals for wellness and for accomplishing the recipient’s plan of care objectives. The ultimate goal of the plan must be to enable recipients to live a dignified life in the least restrictive setting appropriate to their needs. The entire care planning process must be documented in the case record.

Fifth paragraph deleted

Page 2-20 Service Documentation Requirements and Provider Responsibilities: Introduction.

The Introduction is changed to read:

Medicaid will only reimburse for waiver services that are specifically identified in the approved plan of care by service type, frequency and duration and for which there is sufficient documentation supporting the provision and receipt of the service. Services are authorized indicating frequency of service deemed necessary in the plan of care.

Page 2-25 AL Waiver and Covered Services: Medication Administration Component

Second paragraph is changed to read:

ALF staff should be aware of DOEA’s requirement that assistance with self-administered medications can be provided either by a licensed nurse or, with a documented request and informed consent, an unlicensed staff member. The unlicensed staff member must be trained to assist residents with self-administered medications, in accordance with subsection 58A-5.0191(5), Florida Administrative Code, and must demonstrate the ability to accurately read and interpret a prescription label.

Third paragraph is changed to read:

Pursuant to Section 429.256, Florida Statutes, assistance with self-administration of medications includes taking the medication from where it is stored and delivering to the resident; removing a prescribed amount of medication from the container and placing it in the resident’s hand or another container; helping the resident by lifting the container to their mouth; applying topical medications; and keeping a record of when a resident receives assistance with self-administration of the medications.

Page 2-32 Appeal Rights and Fair Hearing Process: Right to a Fair Hearing

First paragraph is changed to read:

In accordance with Chapter 42, Section 431.221 of the Code of Federal Regulations, a recipient has certain appeal rights. A recipient has the right to appeal any action taken by AHCA, DOEA, DCF or service providers that adversely affects the receipt of services. Advance notice of termination of services or program participation must inform the AL recipient of the right to a fair hearing.

Page 3-2 Reimbursement Information, continued: Introduction, continued

Second paragraph is changed to read:

The AL waiver services are paid on a capitated basis. Under a capitated payment, the provider is paid a set fee for each service performed and billed.

Page 3-3 Reimbursement Information, continued: Fee Schedule.

Second paragraph, third bullet is deleted

Page 3-5 Reimbursement Information, continued: Billing for ACS and Assisted Living Waiver Services.

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