AGENCY FOR HEALTH CARE ADMINISTRATION
RULE NO.:RULE TITLE:
59G-4.193Statewide Medicaid Managed Care Long-term Care Waiver Program Prioritization and Enrollment
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. 41 No. 186, September 24, 2015 issue of the Florida Administrative Register.
Substantial rewording of Proposed Rule 59G-4.193 Florida Administrative Code, follows. See the Florida Administrative Register for present text.
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) 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.
(b) Authorized Representative – As defined in section 409.962, Florida Statutes (F.S.).
(c) Enrollment - When the Agency for Health Care Administration (AHCA) places a recipient in a Florida Medicaid managed care plan.
(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.
(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.
(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.).
(g) Rescreening – As defined in section 409.962, F.S.
(h) Screening – As defined in section 409.962, F.S.
(i) Significant Change – As defined in section 409.962, F.S.
(j)Wait List – A list, maintained by DOEA, of individuals who have been screened and assigned a 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 methodology, incorporated by reference and available at http://elderaffairs.state.fl.us/doea/SMMCLTC/2014_Priority_Score_Calculation.pdf.
(b) Priority scores are grouped into frailty-based 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.
(c) Individuals eligible for prioritization on the wait list must live in a LTC program waiver service area.
(d) When the screening process is complete, DOEA will provide the individual, or their authorized representative, a notification of wait list placement including all of the following:
1. The individual’s priority rank.
2. Contact information for the ADRCs.
3. Instructions for requesting an administrative fair hearing in accordance with Title 42, Code of Federal Regulations (CFR), section 431, Subpart E.
4. Instructions for requesting a copy of the completed screening tool, which includes the priority score.
5. Instructions for requesting a rescreening. The individual, or their authorized representative, may request a rescreening due to a significant change.
(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, to 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.
4. Providing instructions for requesting an administrative fair hearing.
(f) The 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 AHCA Form 5000-3008, (JUN 2016), Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, 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.
(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.
(h) The Agency for Health Care Administration will enroll individuals in the LTC program who have been released from the waitlist and meet the eligibility criteria specified in section 409.979, F.S.
(4) Exclusion. This rule is not applicable to Institutional Care Program (ICP) applicants or ICP recipients residing in nursing facilities.
Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409. 978, 409.979(3) FS. History–New________.
