This Section provides guidance for those who are not currently on Medicaid, yet are “ready to apply” for Medicaid services in the home or in the assisted living facility. You are only “ready to apply” when you have been notified, usually by a representative from the Department of Elder Affairs (DOEA) CAREs team, that there is an opening for you in the program.
Home & Community Based Services (HCBS) is the Medicaid program which covers both in-home and assisted living facility services. Most elderly persons have had to wait for several months on a list before being given an open slot in the HCBS program. There is a long, long waiting list of senior citizens who need these in-home or assisted living facility services due to budgetary restrictions imposed by the Florida Legislature.
If you are not aware of the HCBS services, the waiting list, or how to be placed on the waiting list, then we recommend that you obtain comprehensive guidance about Medicaid rules and procedures and what you should do next. Medicaid has a long list of rules relating to “how much income you can have” and “how much money you can have”. We strongly recommend you seek the guidance of an elder law expert who has the special skills and knowledge to help you make decisions applicable to your specific situation.
Here are some of the most important questions for which answers have been provided.
What if I have been notified of an open slot for in home or assisted living Medicaid?
When you have been notified there is an open slot for you in the HCBS program, you are ready to move forward. The final goal at this stage in the process is to have completed all steps necessary to be able to select and enroll in a Managed Care Plan.
Do not delay in completing two major tasks: (1) You need to turn in an application to the Department of Children & Families to assess and approve your financial eligibility; and (2) You need to have been assessed for medical eligibility known as a Level of Care (LOC) assessment, usually performed by a case manager from the DOEA CAREs team. Only after BOTH of these tasks have been completed can you move toward the selection and enrollment process under the new Medicaid Managed Care program. You will not have any contact with a Managed Care Plan, or be allowed to enroll in a Plan, or access any services from a Plan, prior to the completion of these two tasks.
How do I apply for Medicaid?
When this question is asked, it is usually pertaining to applying for some Medicaid program (food stamps, nursing home, medically needy, HCBS, etc.) and being determined financially eligible to receive the program’s benefits according to its income and asset guidelines. It is the Department of Children & Families in the State of Florida which assesses and approves a person’s financial eligibility. You can apply online at www.myflorida.com/accessflorida. If you need assistance with applying or you are concerned you may not meet all income and asset criteria, then you may seek the guidance of an elder law expert to assist you.
After applying for Medicaid and getting my medical assessment, what is my next step?
It is the responsibility of the Department of Children & Families to notify Automated Health Systems (AHS, otherwise known as the Enrollment Broker) that you have filed an application seeking financial approval. It is the responsibility of the Department of Elder Affairs CAREs to notify AHS that you have been assessed and meet the medical criteria. After AHS has received confirmation from both DCF and DOEA, the State of Florida advises you to select a new Medicaid Managed Care Plan (Plan) which will oversee your care as well as determine the amount of services you receive in the future. Enrollment in a Plan will be mandatory. And, if you do not choose a Plan, then the State assigns you to one of the State-approved Plans.
Note: Managed Care Plans are not allowed by law to contact you prior to notification by AHS of your filing a Medicaid application and obtaining a care assessment for medical eligibility.
While I’m waiting for DCF to approve my financial application, am I required to enroll in a Plan?
This is a very good question, and the answer is complicated. The simple answer is “No”, you are not required to enroll in a Plan until you have received an approval from the Department of Children & Families on your financial eligibility for Medicaid HCBS coverage. When you receive your financial approval, then you will need to follow the same process as any other new enrollee into the statewide Medicaid Managed Care program.
However, there are significant benefits to going ahead with the selection and enrollment process in a Plan, rather than waiting until your financial application is approved by DCF. If you do decide to receive services prior to DCF financial approval, you will be given the designation of “Medicaid Pending” in the State’s computer system, or “MEDP” for short.
There are significant benefits to going ahead with the selection and enrollment process in a Plan, rather than waiting. So do not be discouraged by a state representative before you have weighed the benefits against the downsides of beginning service at your earliest opportunity.
What are the benefits of enrolling with a Plan before I receive financial approval for my Medicaid application?
Services! The primary benefit to enrolling is to have the opportunity, at the earliest possible moment, to begin to receive services. Starting services translates into another significant benefit associated with Medicaid approval if you are residing in an assisted living facility: a reduction in the private pay rate. If you delay enrollment, you simply forego any ability to receive services; and, if you live in an ALF, you do not obtain the benefit of a reduction in the amount you privately pay out-of-pocket to the assisted living facility. You will have to wait until Medicaid approval before you receive services or secure a decrease in the amount you pay the assisted living facility.
It is possible to select a Plan and enroll with a Plan before financial approval, yet choose not to receive services from the Plan right away. This means you have enrolled with a Plan but have decided to wait to receive services until the financial approval from DCF is received.
What are the downsides of enrolling with a Plan before I receive financial approval for my Medicaid application?
One downside to enrolling in a Plan is that you will be locked into this Plan until your financial approval comes from DCF. You will not be able to switch Plans during this time period you are pending financial approval. You will only be allowed to disenroll from the Plan. And, if you have started services, your services will have to end when you disenroll from the Plan. You will be without services until all of the following occur: (1) you are financially approved by DCF; (2) you go through the selection process with a new Plan; and (3) you have met with the new Plan to begin your services again. Since Plans only work on a calendar month basis, services will only begin on the first of the calendar month AFTER the month your enrollment paperwork has been processed. If you are the victim of poor timing, you may be without services for quite a while.
Another downside to enrolling in a Plan and beginning to receive services is the risk that your application for financial approval may be denied by the Department of Children & Families. This means the services you have received from the Plan have not been paid for by the State of Florida as a part of your Medicaid approval. The denial means you received services from the Plan for which you now need to pay from your own pocket. Although it is not mandatory for the Plan to seek reimbursement, a Plan is permitted by the State to do so. Yet, the Plan is limited as to what it may charge you discussed below.
Although there are no guarantees, in cases where you have relied upon an elder law expert in qualifying for and filing for Medicaid, the risk of not receiving financial approval by the Department of Children & Families is minimal at best. Simply understand, you need to know that you may encounter “discouragement” from a State’s representative against enrolling and asking to begin services while pending financial approval. The representative will explain that you will be financially responsible for the services the Plan provides you. However, you must carefully weigh the benefits against the downsides in this decision as you do in every other important decision regarding your care and wellbeing. This is your choice to make!
What can a Plan charge me for services received if I am not financially approved for Medicaid coverage?
The Plan may seek reimbursement from you only for documented services, claims, copayments and deductibles paid on your behalf which have been covered under your Plan and only during the period in which the Plan should have received payment (the capitated rate) from the State of Florida for you while in this pending enrollment status. The Plan sends you an itemized bill for services. This itemized bill and related documentation shall be included in your records with the State. If you believe you been charged for more, you may want to ask for guidance from an elder law expert, and/or you may want to file a complaint.
Who are the Plans that have been approved by the State and how do I select one?
A 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.
You will select your Plan by contacting Automated Health Systems (AHS). The State of Florida has hired this company to act as an “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 1-877-711-3662. 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.
If you reside in an assisted living facility, you MUST check to see with which Plans the assisted living facility has contracts. If your assisted living facility has no contracts with any of the Plans in your region, you will have to move to a different assisted living facility or forego Medicaid coverage.
What are the services I’ll receive under this new program?
All 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.
What happens during the meeting with the Plan representative?
After you have selected a Plan, you will be contacted by a Plan’s representative. The Plan’s representative is under a deadline of 5 days to meet with you from the time of your official enrollment. This means that within 5 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 care plan upon which the Plan will provide services or provide oversight to the services provided to you by another health care provider (i.e. the assisted living facility). During this meeting your care needs will be assessed. From this 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.
What if the Plan wants to help with my Medicaid application?
By law, the Plans are not allowed to contact you until you have completed the two tasks of obtaining medical eligibility and filing an application for financial approval. After this, however, the Plans are required by the State of Florida to assist anyone who is pending financial approval with completing the Medicaid application process. If you do not want the Plan to assist you because you are already working with an elder law expert, let the Plan representative know this upfront. You may decline to answer certain questions or decline to produce sensitive financial documents requested by the Plan representative during your care plan meeting. Rather, you may want to provide the Plan representative with the contact information for your elder law expert for questions regarding your Medicaid application.
What if I don’t believe I am receiving an adequate level of services from the Plan?
If you believe that the amount of services and/or the type of services you receive under the Plan are less than what you need and/or deserve, you have the legal right to complain. Yet, you must make your complaint in a specific manner and within a short time-frame. Please see the section toward the end of this booklet marked with the “unhappy face” symbol and the color red.
If I want to change the Plan into which I have been enrolled, what should I do?
As one of the downsides discussed above, if you enrolled in a Plan before obtaining financial approval for your Medicaid application, you are not allowed to change Plans. You may only dis-enroll, and this affects any services you may have begun to receive. Upon financial approval, you may select a Plan as a new enrollee (enrolling for the first time) or you may choose a new Plan after dis-enrolling. In either situation, 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.
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?
There 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, if you live in an assisted living facility, it only entered into a contract with one Plan, and it is not the Plan you selected.
If you reside in an assisted living facility, you MUST check to see with which Plans the assisted living facility has contracts. If your assisted living facility has no contracts with any of the Plans in your region, you will have to move to different assisted living facility or forego Medicaid benefits.
Will I have to move to different assisted living facility?
The scary answer to this question may be “Yes”. You may have to move to a different assisted living facility. Yet, this is only in the cases where you selected a Plan with which your provider did not contract. Since not all assisted living facilities are going to participate in the new Medicaid Managed Care program, you must know which Plan with whom your Provider has a contract. Unfortunately, if your Provider has not contracted with any Plan, the reality is that you may have to move to a different assisted living facility.
IMPORTANT: Talk to your assisted living facility and ask: “With whom have you contracted? It is important for me to know as soon as possible so I can select the Plan that works with you in order for me to remain on Medicaid and not have to move.”
Can I have my family member provide me my services in the home and get paid for it by the Plan?
Yes. If you are living in your own home, you have the option of choosing to receive your care from a person you select yourself. This person can be a family member, a relative, or even a neighbor. In addition, the money which would be spent on paying a Provider (home health agency) to provide you your in-home services can be used to pay your family member, relative or neighbor instead. This program is known as the “Participant Direction Option”. And, the State of Florida was required by the federal government to make it a part of the new Medicaid Managed Care program for long term care services.
After an elderly person has enrolled with a Plan, and subsequently meets with a Plan representative, the representative is required to offer the elderly person the PDO option. There are requirements the elderly person must meet and responsibilities that an elderly person must be able to fulfill. Yet, the Plan must pre-screen each prospective participant. The federal government also requires the Plan to provide adequate support and training to the elderly person and caregiver to understand how to use the self-directed service options.
If you live in your own home and you are in a region that has already rolled out, remember that the federal government has required that you be offered the opportunity to participate in the PDO. This offer should have been discussed with you by the Plan representative who met with you upon your enrollment. If the Plan representative did not discuss this option with you, and this is something that you would have been interested in, you may want to make a formal complaint now.