Fla. Admin. Code R. 59G-4.193

Current through Reg. 50, No. 235-239, December 10, 2024

Section 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) High Priority Rank -Number indicating an individual's assessed need for LTC services and placement on the wait list, based on priority ranks of 3 and above in accordance with paragraph (3)(b) of this rule.

(e) 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.

(f) Low Priority Rank - Number indicating an individual's assessed need for LTC services, based on priority ranks of 1 or 2.

(g) 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.

(h) 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.).

(i) Rescreening - As defined in Section 409.962, F.S.

(j) Screening - As defined in Section 409.962, F.S.

(k) Significant Change - As defined in Section 409.962, F.S.

(l) 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. Rank 2: 16-29.

2. High Priority Score

a. Rank 3: 30-39.

b. Rank 4: 40-45.

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

d. Rank 6: Aging Out Referral.

e. Rank 7: Imminent Risk.

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

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

(d) When the screening process is complete, DOEA will provide the individual, or their authorized representative, written notification of 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, Section 409.285, F.S., and Rule 65-2.042, F.A.C.

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.

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

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

(4) Individuals may bypass the screening and wait list process to enroll in the LTC program in accordance with Section 409.979, F.S.

(5) 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.

Fla. Admin. Code Ann. R. 59G-4.193

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409. 978, 409.979 FS.

Adopted by Florida Register Volume 42, Number 227, November 22, 2016 effective 12/8/2016, Amended by Florida Register Volume 47, Number 130, July 7, 2021 effective 7/20/2021.

New 12-8-16, Amended 7-20-21.