The purpose of new Rule 59G-4.193 is to define the method used to prioritize individuals for placement onto the Statewide Medicaid Managed Care Long-term Care program (LTC program) waitlist and to define the subsequent process for releasing ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.193Statewide Medicaid Managed Care Long-term Care Waiver Program Prioritization and Enrollment

PURPOSE AND EFFECT: The purpose of new Rule 59G-4.193, F.A.C., is to define the method used to prioritize individuals for placement onto the Statewide Medicaid Managed Care Long-term Care program (LTC program) waitlist and to define the subsequent process for releasing individuals for enrollment into the LTC program.

SUMMARY: This rule applies to individuals residing in the community who are seeking Medicaid coverage for home and community-based services through the LTC program. The title of the rule is changed to Statewide Medicaid Managed Care Long-term Care Waiver Program Prioritization and Enrollment.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: 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.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to Section 120.541, Florida Statutes, the rule will not require legislative ratification.

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

RULEMAKING AUTHORITY: 409.919, 409.961 FS.

LAW IMPLEMENTED: 409.979(3) FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: Wednesday, November 12, 2014, 2:00 p.m. ‒ 3:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room A, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Kelly Walsh. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Kelly Walsh, Bureau of Medicaid Services, 6800 N. Dale Mabry Hwy. Suite 220, Tampa, FL 33614, telephone: [phone], e-mail: [e-mail]

Please note that a preliminary draft of the reference material, if available, will be posted prior to the public hearing at http://ahca.myflorida.com/Medicaid/review/index.shtml. Comments will be received until 5:00 p.m. on Thursday, November 13, 2014.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-4.193 Statewide Medicaid Managed Care Long-term Care Waiver Program Prioritization and Enrollment.

(1) Definitions.

(a) Agency for Health Care Administration (AHCA) – The single state agency, or its designee, responsible for administering the Florida Medicaid program.

(b) Aging and Disability Resource Center – An agency designated by the Department of Elder Affairs (DOEA) to perform functions pursuant to Chapters 409 and 430, Florida Statutes (F.S.).

(c) Assessed priority consumer list (herein referred to as waitlist) – A list maintained by DOEA of individuals who have completed the scoring and placement process prior to enrollment in the home and community-based services portion of the LTC program.

(d) Assessed priority pipeline list (APPL) – A list maintained by DOEA of individuals who have been released from the LTC program waitlist for potential enrollment into the LTC program.

(e) Authorized or designated representative – An individual who has the legal authority to make decisions on behalf of a Medicaid enrollee or potential Medicaid enrollee in matters related to the managed care plan.

(f) Department of Elder Affairs – The primary state agency, or its designee, responsible for administering human services programs to benefit Florida’s elders, pursuant to Chapter 430, F.S. The Department of Elder Affairs, or its designee, performs waitlist functions pursuant to Chapter 409, F.S., and Chapter 2014-53, Laws of Florida.

(g) Disenrollment – The Agency for Health Care Administration’s approved discontinuance of a recipient’s participation in a Medicaid managed care plan.

(h) Enrollment – The process by which an eligible Medicaid recipient signs up to participate in a Medicaid managed care plan.

(i) Long-term Care program (LTC) – The LTC program, as referenced in Chapter 2014-53, Laws of Florida and Chapter 409.978 F.S., is a component of the Statewide Medicaid Managed Care program.

(j) Priority Score – A number between 0 and 105, inclusive, that indicates an individual’s need for services and which is used to prioritize an individual’s enrollment in the home and community-based services portion of the LTC program. The score is generated automatically when the screening form is completed and entered into DOEA’s referral tracking system.

(k) Rescreening – The use of Screening Form (701S) or Comprehensive Assessment (701B) by DOEA certified staff to conduct  annual screenings or screenings due to a significant change.  Annual screenings must occur within 13 months of the previous screening.

(l) Screening – The use of Screening Form (701S) or Comprehensive Assessment (701B) by DOEA certified staff for initial screenings, which must occur prior to placement on the waitlist.

(m) Significant change – A change in an individual’s health status after an accident or illness; change in living situation; change in the caregiver relationship; loss, damage, or deterioration of the home environment; or loss of spouse  or caregiver. 

(2) Purpose.

(a) This rule applies to individuals residing in the community who are seeking Medicaid coverage for home and community-based services through the LTC program. This rule does not apply to Institutional Care Program (ICP) recipients residing in nursing facilities or ICP applicants.

(b) The Department of Elder Affairs and the Agency for Health Care Administration may limit enrollment into the LTC program pursuant to Chapter 409, F.S., in order to not exceed:

1. The number of Medicaid recipients who may be enrolled, or who are projected to be enrolled, in the LTC program, and the total LTC program allocation in the General Appropriations Act.

2. The cost to serve the total number of individuals in the APPL.

(c) A certified DOEA staff person completes the screening for each individual requesting enrollment in the LTC program. The individual requesting LTC program services, or the individual’s authorized or designated representative, must participate in an initial screening. The screening form must be completed in its entirety for placement on the waitlist for the LTC program.

(d) The completion of the screening form in DOEA’s referral tracking system automatically generates a priority score, which is used to prioritize an individual’s order of enrollment onto the LTC program, and completes the process of placement on the waitlist. DOEA maintains one statewide waitlist for the LTC program.

(e) Only individuals whose domicile is in Florida are eligible for initial and continued prioritization on the waitlist.

(f) The Department of Elder Affairs must perform a rescreening annually for an individual to remain on the waitlist. Individuals must keep appointments with DOEA to furnish information and documentation needed to complete the screening process for the LTC program, including their correct and current name, mailing address, and telephone numbers.

(g) The specific methodology used to calculate an individual’s priority score is available on DOEA’s Web site at http://elderaffairs.state.fl.us/doea/SMMCLTC/2014_Priority_Score_Calculation.pdf.

Priority scores are grouped into levels or categories (referred to as “ranks”) as follows:

1. Rank 1: 0-15

2. Rank 2: 16-29

3. Rank 3: 30-39

4. Rank 4: 40-45

5. Rank 5: = 46

(h) The following individuals are eligible to transition into the LTC program home and community-based services waiver without completing the screening or waitlist placement process if all other LTC program eligibility requirements are met:

1. Nursing facility residents who have resided in a Florida-licensed skilled nursing facility for at least 60 consecutive days.

2. Medically complex recipients, as defined in Rule 59G-1.010, F.A.C., ages 18, 19, or 20.

3. Individuals referred by the Florida Department of Children and Families (DCF) Adult Protective Services as high risk.

(i) Upon completion of the waitlist placement, DOEA shall provide the individual, or their authorized or designated representative, with a notification of waitlist placement, along with notice of the administrative fair hearing process and their rights in accordance with Title 42, Code of Federal Regulations, Section 431.200, F.A.C., et seq.

(j) The individual, or their authorized or designated representative, may request a rescreening due to a significant change.

(k) If DOEA is unable to contact the individual to schedule an initial screening, significant change rescreening, or annual rescreening, DOEA will send written correspondence to the last documented address of the individual, or to the authorized or designated representative listed for that individual. The written correspondence will request that the individual contact DOEA within ten business days of the date of the notice and notify the individual that he or she may be terminated from the screening process or waitlist due to DOEA’s inablity to successfully make contact and perform the screening or rescreening. If the individual does not keep an appointment without arranging another time with DOEA, DOEA will not complete the initial screening or rescreening and shall terminate an individual from the screening process or the waitlist.

(l) An individual will not remain on the waitlist if he or she does not have a current priority score, no longer wishes to remain on the waitlist, is no longer eligible to receive services, begins the eligibility process for the LTC program, or begins receiving LTC program services.

(m) The Department of Elder Affairs can substantiate and document information provided by the individual as part of the screening process or as part of placement on the waitlist. DOEA may ask for additional documentation or may obtain information from other agencies, as necessary.

(n) Prior to LTC program enrollment, individuals must be determined financially and clinically eligible for the LTC program. If financial or clinical eligibility cannot be determined, DOEA will notify the individual, or the individual’s authorized representative, that he or she shall be terminated from the waitlist.

1. The Department of Elder Affairs determines clinical eligibility, in accordance with Rules 59G-4.180 and 59G-4.290, F.A.C.

(a) The Department of Elder Affairs will send written notice to the last known address of the individual, or to the authorized or designated representative of the individual, requesting that the individual secure a completed and signed AHCA MedServ-3008 form. The individual must return the completed form to DOEA within 30 calendar days of the date of the notice.

(b) Department of Elder Affairs staff will contact the individual to schedule completion of the Comprehensive Assessment (701B). If the individual cannot be reached to schedule and complete the Comprehensive Assessment (701B), clinical eligibility cannot be determined.

2. The Department of Children and Families determines financial eligibility for Medicaid, pursuant to Rule 65A-1.205, F.A.C. If the individual does not have the appropriate Medicaid financial eligibility to participate in the LTC program, the notice from DOEA will inform the individual that an ACCESS Florida Application for Medicaid Waiver/Home and Community Based Services must be submitted to DCF within 35 calendar days from the date of the notice.

(3) The following form is incorporated by reference, in this rule: Medical Certification for Nursing Facility/Home-and Community-Based Services Form, AHCA MedServ-3008 form, May 2009. The form is available from the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Forms. The following forms are incorporated by reference in Rule 58A-1.010, F.A.C.: Comprehensive Assessment (701B), Revised April 2013, and Screening Form (701S), Revised April 2013. These forms are available on DOEA’s Web site at http://elderaffairs.state.fl.us/index.php. Select Publications and Reports, then DOEA Publications and Reports, then DOEA Forms, then Assessment Forms, and then the PDF.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409.979(3) FS. History–New__________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Kelly Walsh

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: October 17, 2014

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: June 9, 2014