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 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.

SUMMARY: 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 and describes the methodology for prioritizing enrollment of and enrolling these individuals.

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: 409.978, 409.979(3) FS.

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

DATE AND TIME: October 21, 2015, 1:30 p.m. ‒ 2:30 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 Raborn. 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 Raborn, 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 the date of the hearing.

 

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 (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 the age of 60 years, age out of CCDA or HCDA, and are screened and prioritized for programs serving individuals who are age 60 years 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. The Department of Elder Affairs, or its designee, performs priority list functions pursuant to Chapter 409, F.S., and Chapter 2014-53, Laws of Florida.

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

(i) Enrollment - The process by which an eligible Florida Medicaid recipient signs up to participate in a Florida 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 facility placement is likely within a month, or very likely within three months.

(k) Long-term Care (LTC) program - The LTC program, referenced in Chapter 2014-53, Laws of Florida and section 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, 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) The Department of Elder Affairs and AHCA may limit enrollment into the LTC program pursuant to Chapter 409, F.S., to prevent exceeding:

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 home and community-based service portion of 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, used to prioritize an individual’s order of enrollment into the LTC program, and completes the process of placement on the priority list. The Department of Elder Affairs 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) The Department of Elder Affairs 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 correct and current name, mailing address, and telephone number(s).

(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: greater than or equal to 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 home and community-based services portion of the LTC program 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.), who are 18, 19, or 20 years of age.

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, 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, and Title 42 CFR 438, Subpart F – Grievance System.

3. Instructions for requesting a copy of the completed screening form, which shall include the priority score.

4. Instructions for requesting a rescreening.

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) The Department of Elder Affairs may remove individuals from the screening process or priority list for one of the following reasons:

1. The Department of Elder Affairs 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 DOEA appointment, 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 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 because of 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, Subpart E, and section 438, Subpart F.

(m) Notification that 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. The Department of Elder Affairs determines clinical eligibility, in accordance with Rules 59G-4.180 and 59G-4.290, F.A.C.

2. The Department of Children and Families 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 information is incomplete.

(o) 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, with instructions about the requirements for a completed and signed AHCA MedServ Form 5000-3008, October 2015, Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form submission, incorporated by reference in Rule 59G-1.045, F.A.C. The form is available on the AHCA fiscal agent’s Web site at http://portal.flmmis.com/flpublic. The individual must return the completed form to DOEA within 30 calendar days of the date of the notice.

(p) The Department of Elder Affairs 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) 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 priority list. The Department of Elder Affairs 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.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409. 978, 409.979(3) FS. History–New________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Kelly Raborn

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

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 15, 2015

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 5, 2015