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 (SMMC) Long-term Care (LTC) program priority list 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 (SMMC) Long-term Care (LTC) program priority list and to define the subsequent process for releasing individuals for enrollment into the LTC program. This rule applies to individuals residing in the community who are seeking Florida Medicaid coverage for home and community-based services through the LTC program.

SUBJECT AREA TO BE ADDRESSED: Statewide Medicaid Managed Care Long-term Care Waiver Program Prioritization and Enrollment.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-4.193, F.A.C. will have as provided for under sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.919, 409.961 FS.

LAW IMPLEMENTED: 409.978, 409.979(3) FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: May 27, 2015, 1:00 p.m. ‒ 2:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, 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 DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Kelly Walsh, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

Comments will be received until 5:00 p.m., on June 3, 2015.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT 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 (ADRC) - An agency designated by the Department of Elder Affairs (DOEA) to perform functions pursuant to Chapters 409 and 430, Florida Statutes (F.S.).

(c) Aging out - Department of Children and Families (DCF) clients enrolled in the Community Care for Disabled Adults (CCDA) or Home Care for Disabled Adults (HCDA) program who, at age 60, age out of CCDA or HCDA and are screened and prioritized for programs serving individuals age 60 and older.

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

(e) Assessed priority pipeline list (APPL) - A list maintained by DOEA of individuals who have been released from the LTC program priority list for potential enrollment into the home and community-based portion of the LTC program.

(f) Authorized or designated representative - An individual who has the legal authority to make decisions on behalf of a Florida Medicaid enrollee or potential Florida Medicaid enrollee in matters related to the managed care plan, screening, or eligibility process.

(g) 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. DOEA, or its designee, performs priority list functions pursuant to Chapter 409, F.S., and Chapter 2014-53, Laws of Florida.

(h) Disenrollment – AHCA’s approved discontinuance of a recipient’s participation in a Medicaid managed care plan.

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

(j) Imminent risk - Individuals in the community whose mental or physical health condition has deteriorated to the degree that self-care is not possible, there is no capable caregiver, and nursing home placement is likely within a month or very likely within three months.

(k) Long-term Care (LTC) program - 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 (SMMC) program.

(l) Priority rank - A number between 1-8 that indicates an individual’s need for services that is used to prioritize an individual’s release from the priority list for enrollment in the home and community-based services portion of the LTC program. The priority rank is generated automatically following the calculation of an individual’s priority score when the screening form is completed and entered into DOEA’s referral tracking system.

(m) Priority score - A number between 0 and 105, inclusive, that indicates an individual’s need for services. The priority score generates a priority rank, which is used to prioritize an individual’s release from the priority list for the home and community-based services portion of the LTC program. The priority score is generated automatically when the screening form is completed and entered into DOEA’s referral tracking system.

(n) 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.

(o) 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 priority list.

(p) 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 Florida Medicaid coverage for home and community-based services through the LTC program. No waiting list exists for Institutional Care Program (ICP) nursing facility services. The mandates of this rule specifically related to priority list placement and release for enrollment in the home and community-based portion of the LTC program are not applicable to ICP applicants or ICP recipients residing in nursing facilities.

(b) DOEA and AHCA may limit enrollment into the LTC program pursuant to Chapter 409, F.S., in order to not exceed:

1. The number of Florida 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 priority list 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 priority list. DOEA maintains one statewide priority list for the LTC program.

(e) Individuals eligible for initial and continued prioritization on the priority list must live in the LTC program waiver service area.

(f) DOEA must perform a rescreening annually for an individual to remain on the priority list. 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.

6. Rank 6: Aging Out Referral.

7. Rank 7: Imminent Risk.

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

(h) The following individuals are eligible to transition into the LTC program home and community-based services waiver without completing the screening or priority list placement process if all financial eligibility and clinical eligibility requirements for the LTC program are met prior to their enrollment:

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, Florida Administrative Code (F.A.C.), ages 18, 19, or 20.

3. Individuals referred by DCF Adult Protective Services as high risk and placed in an assisted living facility temporarily funded by DCF.

(i) Upon completion of the priority list placement, DOEA shall provide the individual, or their authorized or designated representative, with a notification of priority list placement. The notification of priority list placement shall include all of the following:

1. The individual’s generated priority rank.

2. Instructions for requesting an administrative fair hearing in accordance with Title 42, Code of Federal Regulations (CFR), section 431, Subpart E - Fair Hearings for Applicants and Beneficiaries

3. Instructions for requesting a copy of the completed screening form.

4. Instructions for requesting a re-screening.

5. Contact information for the ADRCs.

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

(k) DOEA may remove individuals from the screening process or priority list for one of the following reasons:

1. DOEA is unable to contact the individual or the individual’s authorized or designated representative to schedule an initial screening, significant change rescreening, or annual rescreening.

2. The individual, or the individual’s authorized or designated representative, does not keep an appointment with DOEA without scheduling another appointment time.

(l) If DOEA is unable to contact the individual, or the individual’s authorized or designated representative, to schedule an initial screening, significant change rescreening, or annual rescreening, or the individual does not keep an appointment with DOEA, DOEA will:

1. 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 30 business days of the date of the notice and notify the individual that he or she may be removed from the screening process or priority list due to DOEA’s inablity to successfully make contact and perform the screening or rescreening.

2. The written correspondence will include the following:

a. Instructions for re-initiating the screening or priority list placement process, including instructions for requesting a rescreening and for contacting the ADRCs.

b. Instructions for requesting an administrative fair hearing in accordance with Title 42, CFR, section 431.200, et. seq.

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

(n) Prior to LTC program enrollment, individuals must be determined financially and clinically eligible for the LTC program.

1. DOEA determines clinical eligibility, in accordance with Rules 59G-4.180 and 59G-4.290, F.A.C.

2. DCF determines financial eligibility for Florida Medicaid, pursuant to DCF Rule 65A-1.205, F.A.C. Individuals will receive notice 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, if LTC program eligibility is incomplete.

(o) DOEA will send written notice to the last known address of the individual, or to the authorized or designated representative of the individual, with instructions about the requirements for a completed and signed AHCA MedServ Form 5000-3008, Medical Certification for Medicaid Long-term Care Services and Patient Transfer submission. The individual must return the completed form to DOEA within 30 calendar days of the date of the notice.

(p) DOEA 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.

(q) If an individual believes they have been removed from the screening process or priority list in error, the individual, or their authorized or designated representative, may contact the ADRC at any time to reinitiate their screening process or priority list placement.

(r) DOEA can substantiate and document information provided by the individual as part of the screening process or as part of placement on the priority list. DOEA may ask for additional documentation or may obtain information from other agencies, as necessary.

(3) 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. 978, 409.979(3) FS. History–New________.