The purpose of the amendment to Rule 59G-4.193, Florida Administrative Code (F.A.C.), is to revise the prioritization process for the Statewide Medicaid Managed Care Long-term Care (LTC) Waiver Program. The amendment will ....

 

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 the amendment to Rule 59G-4.193, Florida Administrative Code (F.A.C.), is to revise the prioritization process for the Statewide Medicaid Managed Care Long-term Care (LTC) Waiver Program. The amendment will address the screening tool and the scoring methodology for inclusion and prioritization on the LTC wait list.

SUMMARY: 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, (F.S.) 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: 409.978, 409.973 FS.

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

DATE AND TIME: March 25, 2021, 3:30 p.m. to 4:00 p.m.

PLACE: Remote Listeners: Attendees may register for the hearing at: https://attendee.gotowebinar.com/register/1977425896427842316. After registering, a confirmation email will be received containing information about joining the webinar, and opportunities to offer comments and questions will be available.

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 7 days before the workshop/meeting by contacting: [e-mail]. 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: [e-mail]. Please note that a preliminary draft of the reference material, if available, will be posted prior to the hearing at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m. on March 26, 2021 and may be e-mailed to [e-mail].

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

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

(1) This rule applies to individuals living in their home, or a community setting, who are seeking Florida Medicaid coverage for home and community-based services (HCBS) through the Florida Medicaid Statewide Medicaid Managed Care Long-term Care (LTC) program.

(2) Definitions. The following definitions are applicable to this policy.

(a) Adult Protective Services High Risk Referral – Individuals age 60 or older who are determined by Department of Children and Families Adult Protective Services to be victims of abuse, neglect, or exploitation, who need immediate services to prevent further harm.

(b)(a) Aging Out – When an individual who is enrolled in the Department of Children and Families’ (DCF) Community Care for Disabled Adults or Home Care for Disabled Adults program reaches the maximum age for the program and is referred for screening and prioritization for the LTC program.

(c)(b) Authorized Representative – As defined in section 409.962, Florida Statutes (F.S.).

(d)(c) Enrollment – When the Agency for Health Care Administration (AHCA) places a recipient in a Florida Medicaid managed care plan.

(e) High Priority Rank – Automatically generated number indicating an individual’s assessed need for LTC services and placement on the wait list, based on priority ranks of 3, 4, 5, 6, 7, and 8.

(f)(d) Imminent Risk – When individuals living in their home or a community setting meet all of the following:

1. Unable to perform self-care because of deteriorating mental or physical health condition(s).

2. There is no capable caregiver.

3. Placement in a nursing facility is likely within a month, or very likely within three months.

(g) Low Priority Rank – Automatically generated number indicating an individual’s assessed need for LTC services, based on priority ranks of 1 or 2.

(h)(e) Priority Rank – Automatically generated number indicating an individual’s assessed need for LTC services and to determine placement on the wait list, based on the priority score.

(i)(f) Priority Score – Automatically generated number based on a Department of Elder Affairs’ (DOEA) screening completed in accordance with rule 58A-1.010, Florida Administrative Code (F.A.C.).

(j)(g) Rescreening – As defined in section 409.962, F.S.

(k)(h) Screening – As defined in section 409.962, F.S.

(l)(i) Significant Change – As defined in section 409.962, F.S.

(m)(j) Wait List – A list maintained by DOEA of individuals who have been screened and assigned a high priority rank by an Aging and Disability Resource Center (ADRC).

(3) Process.

(a) The Department of Elder Affairs will prioritize individuals determined eligible for the LTC program pursuant to section 409.979, F.S., in accordance with the priority score determined using the DOEA Priority Score Calculation (November 2014) methodology, incorporated by reference and available at http://elderaffairs.state.fl.us/doea/SMMCLTC/2014_Priority_Score_Calculation.pdf and at http://www.flrules.org/Gateway/reference.asp?No=Ref-07525.

(b) Priority scores are grouped into low and high priority score ranges and frailty-based levels or categories (referred to as “ranks”) as follows:

1. Low Priority Score

a. Rank 1: 0-15.

b.2. Rank 2: 16-29.

2. High Priority Score

a.3. Rank 3: 30-39.

b.4. Rank 4: 40-45.

c.5. Rank 5: Greater than or equal to 46.

d.6. Rank 6: Aging Out Adult Referral.

e.7. Rank 7: Imminent Risk.

f.8. Rank 8: Adult Protective Services High Risk Referral.

(c) Individuals eligible for prioritization on the wait list must live in ana LTC program waiver service area.

(d) When the screening process is complete, DOEA will provide the individual, or their authorized representative, written notification of wait list placement including all of the following:

1. For individuals with a high priority rank, notification of wait list placement.

2.1. The individual’s priority rank.

3.2. Contact information for the ADRCs.

4.3. Instructions for requesting an administrative fair hearing in accordance with Title 42, Code of Federal Regulations (CFR), Section 431, Subpart E.

5.4. Instructions for requesting a copy of the completed screening tool, which includes the priority score.

6.5. Instructions for requesting a rescreening. The individual, or their authorized representative, may request a rescreening due to a significant change.

7. For individuals with a low priority rank, notification of ineligibility for wait list placement and information on how to find community resources available to assist them.

(e) The ADRCs will administer rescreening as follows:

1.  For individuals with a low priority rank, the ADRCs may administer rescreening upon request annually or will administer rescreening upon notification of a significant change in an individual’s circumstances.

2. For individuals with a high priority rank, the ADRCs will administer rescreening annually or upon notification of a significant change in an individual’s circumstances.

(f)(e) If DOEA is unable to contact the individual, or their authorized representative, to schedule an initial screening or rescreening; or if the individual does not keep an appointment for a screening or rescreening, DOEA will send written correspondence to the individual’s, or to their authorized representative’s, last documented address:

1. Requesting the individual, or their authorized representative, contact DOEA within 30 calendar days of the date of the notice.

2. Notifying the individual, or their authorized representative, that the individual may be removed from the initial screening process or wait list if no contact is made.

3. Providing instructions for re-initiating the screening process, requesting a rescreening, and contacting the ADRCs.

(g) The Department of Elder Affairs will maintain the last documented contact information for each individual with a low priority rank for purposes of any future rescreening.

(h)(f) For individuals released from the wait list, tThe Department of Elder Affairs will send written notice to the individual’s, or to their authorized representative’s, last documented address about submission requirements for a completed and signed Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, AHCA MedServ Form 5000-3008, June 2016, incorporated by reference in rule 59G-1.045, F.A.C. The individual, or their authorized representative, must return the completed form to DOEA within 30 calendar days of the date of the notice.

(i)(g) The Department of Elder Affairs will contact the individual, or their authorized representative, to determine clinical eligibility for the LTC program in accordance with rule 58A-1.010, F.A.C.

(j)(h) The Agency for Health Care Administration will enroll individuals who have been released from the wait list and meet the eligibility criteria specified in section 409.979, F.S., in the LTC program.

(4) The following individuals may bypass the screening and wait list process to enroll in the LTC program if all other LTC managed care program eligibility requirements are met:

a. A Medicaid recipient 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.

b. An individual who is referred by the Department of Children and Families pursuant to sections 415.101-415.113, F.S., as high risk and who is placed in an assisted living facility temporarily funded by the Department of Children and Families.

c. An individual who is 18 years of age or older who has been diagnosed with Cystic Fibrosis and who has a hospital level of care.

(5)(4) Exclusion. This rule is not applicable to Institutional Care Program (ICP) applicants or ICP recipients residing in nursing facilities.

(6) This rule is effective for five years after the effective date.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409. 978, 409.979 FS. History–New 12-8-16,__________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Antraneise Jackson

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Shevaun L. Harris

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: February 15, 2021

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: August 28, 2020