Blue Section

 

Current Recipient of Medicaid

Living in the Nursing Home

Conflict Free Advocacy With Expert Legal Knowledge
Follow me on LinkedIn follow me on facebook tweet me

Blue_section_3

If you are currently on Medicaid now – this means you are receiving Medicaid covered services in the nursing home – the State of Florida requires you select a new Medicaid Managed Care Plan (Plan) which will oversee your care in the nursing home. The nursing home will have to coordinate, not only your plan of care within the nursing home, but all your needs in the future, including hospitalization, with the Plan.

Your enrollment in a Plan is mandatory. And, if you do not choose one yourself, then the State assigns you to one of the State-approved Plans.

For now… your choice of a Plan for your long term care services will not affect your hospital and doctor Medicare coverages, or your Medicare Medigap policy or Advantage plan coverage. Later in 2014, the second half of the new Medicaid Managed Care program will be implemented, which may require you to make new choices related to your Medicare coverage.

Here are some of the most important questions for which answers have been provided.

 

When must I choose this new Plan?

step_3_blueDuring the statewide program implementation (August 1, 2013 through March 1, 2014), the answer to “when” you must choose a plan depends entirely upon where you live in the State of Florida. Florida has been divided into 11 regions. Depending upon the region in which you live, you have been given a deadline for making your Plan choice before the “roll-out” date for the entire region. See the chart on page 38. For example, Orlando is located in Region 7. An elderly person living in this Region either selected a Plan, or a Plan was selected for him/her by the State, about two weeks before the enrollment date of August 1, 2013. However, an elderly person living in Tampa (Region 6) must let the State know his/her Plan selection about two weeks prior to the enrollment date of February 1, 2014. Prior to these deadlines, the State of Florida sends “welcome letters” enclosing information about the selection process you must follow and the deadlines you are required to meet.

As mentioned above, when you receive your “welcome letter”, you will be given a deadline known as the “auto enrollment date”. Generally, you have been given about 30 days notice to make your own Plan selection. However, as of the auto enrollment date, the State of Florida automatically assigns you to a Plan.

As you can see from the chart on page 38, all regions in the State of Florida will be rolled out by March 1, 2014. In the meantime… Carefully review any and all letters you receive from the State of Florida.

The State of Florida may make a serious mistake and send you a letter which should be sent only for an elderly person living in a region that has rolled out. For instance, you may receive a letter designed for a person living in Sarasota (Region 8), even though you live in Tampa (Region 6). These letters will contain deadlines that are clearly not correct for you, which, in turn, may deny your rights and ability to select the Plan of your own choosing in the future. It also means that the State of Florida may be making payments on your behalf for services you very likely are not receiving! The Plan in which you have been enrolled may not even know who you are or where you are.

Who are the Plans that have been approved by the State?

step_3_blueA total of only 7 Managed Care Companies received approval from the State of Florida to participate in the new Medicaid Managed Care Program. This means you can only choose from among these 7 Plans. Yet, some of these Plans only wanted to cover elderly consumers in specific regions in the State. Not all Plans are in every region. Be careful to review the chart on page 38 to make sure you know which Plans you can choose from within the region you reside.

WARNING: The State of Florida may make a serious mistake and send you information about Plans working in Region 8, yet you live and received Medicaid only in Region 6. Carefully review the information you have received, comparing the Plans on page 38 so that you know from which Plans you may choose correctly. If you need further guidance, we recommend that you contact an elder law expert.

What are the services I’ll receive under this new program?

step_3_blueAll the Plans that have been approved in the State of Florida must offer the same platform of services. Some may offer a bit more or may offer the services in a different manner.

The services that all Plans must offer is shown in a chart on page 29. In the nursing home, the Plan’s services will be concentrated on care coordination and case management, while the long term care facility continues to provide the routine daily services.

How do I let the State know I have made my choice?

step_3_blueThe State of Florida has hired a company known as Automated Health Systems (AHS). AHS is also referred to as the “Enrollment Broker”. Its responsibility is to tell you which Plans are within your region. However, AHS cannot tell you which Plan you should choose. You may contact AHS by toll free number 1-877711-3662. You also may request an in-person meeting to let AHS know which Plan you have selected. Or, you can make your selection of a Plan online by visiting: www.flmedicaidmanagedcare.com.

Once you have made your decision, AHS records your choice into the statewide Medicaid computer system and notifies the Plan you have chosen. You will receive written confirmation from AHCA of your Plan choice. And, in a few days, a representative from the Plan you have selected (usually a case manager) will contact you to arrange a meeting. In addition, you will receive an “insurance card” and a Plan handbook.

Watch out for Plan “Switch-a-Roo” after selection.

WARNING: In the regions that have already rolled out, there have been reports of Plan “switch-aroo”. For example, an elderly person chooses Plan X and made this selection with the Enrollment Broker. Yet, the written confirmation from AHCA states that the elderly person has enrolled in Plan Y. The elderly person has been a victim of Plan “switch-a-roo”. Please pay attention to any and all letters received by AHCA so as to make sure your enrollment is in the Plan that you have actually selected! You will need to take immediate action to correct this “switch-a-roo” which may include contacting the Enrollment Broker again and/or filing a complaint. Please see the section toward the end of the booklet marked with the “unhappy face” symbol and the color, red.

What happens during the meeting with the Plan representative?

step_3_blueAfter you have selected a Plan, or the State of Florida has selected one for you, you will be contacted by a Plan’s representative. The Plan’s representative is under a deadline of 7 days to meet with you from the time of your official enrollment. This means that within 7 days, a representative from the Plan you have chosen must come out and meet with you. This is a requirement by the State of Florida. And, if the Plan representative does not meet with you in this time period, it is subject to fines.

The purpose of this meeting is to assess your needs and develop a new care plan upon which the Plan will provide services or provide oversight to the services provided to you by the nursing home. During this meeting your care needs will be assessed. From this new assessment, the amount of time and frequency of the services you will receive is written down and finalized.

The State of Florida requires that you have input into your care plan. You will be asked to come up with personal goals. You will also be asked to sign the care plan affirming the fact that you have participated fully in the development of the care plan (particularly the part about adding your personal goals).

This plan, made just for you, will remain in effect for up to one full year, so it is crucial to fully participate in its development. Also, you are entitled to have with you during the meeting a friend or family member or advocate, including your elder law attorney who may have assisted you when you first qualified for Medicaid. You should make sure that you are clear in advising the Plan representative that a meeting should only be held when your “trusted advocate” can also attend, particularly if you believe you would like to have your friend or family present while answering questions by the Plan representative. Do not feel rushed to have the meeting without your desired person present just because the Plan has a deadline.

Also, you may decline to answer certain questions or decline to produce sensitive financial documents requested by the Plan representative during this meeting. This meeting is intended to focus on your care and your needs. Consequently, in many cases, these are questions which the Plan representative should not be asking. If you have significant concerns about any documentation requested or any other matters, you may desire further guidance from an elder law expert.

What if my new plan of care changes the services I had been receiving?

step_3_blueIf you believe that the amount of services and/or the type of services you receive under the new Plan are less than what you were receiving before, this reduction is against the law. If there has been any other changes brought as a result of this new care plan, you also are afforded strong protections under the law. Most important, you have the legal right to complain. Yet, you must make your complaint in a specific manner and within a short time frame.

emoticon_sad_facePlease see the Section on page 36 of this guide for a few questions regarding complaints.

What if I want to change my mind?

step_3_blueThe answer to this question depends upon what you want to change your mind about.

You cannot change your mind about participating in the new Medicaid Managed Care program. It is mandatory for all elderly persons receiving Medicaid covering in home, assisted living and nursing home care. However, you are given a small window of opportunity to change your mind after you have made your choice of a Plan, or one has been selected for you by the State.

How long do I have to change my mind?

step_3_blueAfter you receive your “Welcome Letter”, you will have 30 days to select a Plan. If you do not select a Plan, you will be auto enrolled. Following the selection of the Plan or auto enrollment, you have a 90 day time period in which you are allowed to change your mind and select a new Plan. Beyond the 90 day time period, however, you will not be allowed to change your Plan without a really good reason. These are called “good cause” reasons. The State of Florida has provided only a handful of reasons it considers as “good cause” reasons, which would allow you to change Plans after the 90 days have expired. You will be in the Plan until 60 days before your anniversary date, which is called the “open enrollment” period. At that time, your selection process for a Plan begins all over again.

What are some good reasons for changing Plans?

step_3_blueThere are several. The easiest reason is that you simply don’t like the Plan you selected or that got selected for you by the State. Perhaps you received better information, and you believe a different Plan offers better services than the Plan you selected. Or, critical to your ongoing services, your Provider (the nursing home) does not have a current contract with the Plan you have selected.

By law, all nursing homes are required to participate in the new Medicaid Managed Care program and contract with all Plans in the region. Yet, there may be a delay in getting the contract between your nursing home and the Plan approved by the State of Florida. Take the initiative and ask the nursing home: “With which Plans have you had your contract approved? It is important for me to know as soon as possible so I can select the Plan with which you are currently working.”

If you reside in a Region that has already “rolled out”, you still have time to get more information. Based upon the new information you have obtained, you may want to change your mind about the Plan you have selected or have been enrolled in by the State. It may not be the right Plan for you, particularly if you are not happy about the services you are currently receiving.

By law, all nursing homes are required to participate in the new Medicaid Managed Care program and contract with all Plans in the region.

Will I have to move to a different nursing home?

step_3_blueThe answer to this question is “Probably Not”. You will have to move to a different nursing home only if you selected a Plan with which your nursing home did not contract. This will be an extremely rare situation because, by law, all nursing homes must participate in the new Medicaid Managed Care program, contracting with all the Plans in the region. However, after the first year of this new program, the answer to this question may change to be “Yes, you will have to move to a different nursing home.” The State of Florida has given the Plans the authority to end its contracts if the Plan believes the nursing homes have failed to meet the Plan’s performance measures and other quality assurances. If there is no contract with the nursing home in which you reside, then you will need to move to a different nursing home in order to continue your Medicaid coverage.

 

back to top