You may encounter circumstances, such as your choices or the care you receive, where something is just not right. In these cases, you may have a complaint. Discussed in this section are a FEW of the areas where you may have a concern arise.
It is possible you will not see a question or answer addressing your specific situation below. This does not mean your concern is not worthy of a formal complaint. We recommend that you seek assistance from an elder law expert – an attorney who has received a specialized certification from the Florida Bar knowledgeable about these important benefits and legal rights to which you are entitled. In almost all cases, the time period in which you have to make your complaint is greatly limited. And, if you do not act, you may not only lose your right to complain, you may also lose the law’s protection of your important rights.
“In almost all cases, the time period in which you have to make your complaint is greatly limited.”
What if the services I have been receiving suddenly get cut off or reduced? What do I do?
A denial, reduction, suspension or termination of services is called an action. You can request a review of this action by filing an appeal (written or oral) with the Plan within 30 days of receiving the Notice of Action. [A “Notice of Action” is the letter in which you are informed that your services are being denied, reduced, suspended or terminated.] Or, you may request a Medicaid Fair Hearing through the Florida Department of Children and Families (DCF) within 90 days of receiving the Notice of Action. You should receive a notice of results from the Plan within 45 days of the Plan receiving the appeal.
If you have not been told about your rights to file an appeal, then ask. You are required to receive information from the Plan about “your rights to complain”.
Is there an expedited way to appeal through the Plan if my services are cut off or reduced?
Yes, if the standard process would jeopardize your life or health or your ability to attain, maintain or regain maximum function. The Plan must provide a notice of resolution within 72 hours of receiving the appeal request. In almost all cases, the time period in which you have to make your complaint is greatly limited.
Will my services continue after I receive a notice that my previously authorized services are being cut off or reduced?
Yes, but only if you request an appeal with the Plan within 10 days of the mailing date of the Notice or the intended effective date of the action, whichever is later. Make sure to keep the envelope in which you received your Notice and also write down the day you received it in the mail since this is very time sensitive. It is possible that the date the Notice has on it, and the date that it was postmarked when mailed to you, and the date that you received the Notice may be inconsistent with regular US mail service.
How do I file for a Fair Hearing?
Even though this information must be provided to you by the Plan, here is the information you need in order to file for a Fair Hearing in four different ways.
Phone: Call (850) 488-1429
Fax: (850) 487-0662
Department of Children & Families, Office of Appeal Hearings
Building 5, Room 255
1317 Winewood Boulevard
Tallahassee, Florida 32399.
What do I do if I am unhappy with anything OTHER THAN a denial, reduction, suspension or termination of services?
You can first file a complaint with the Plan or the State. Your complaint must be resolved by the end of the next business day or be moved into the grievance system. You can file a grievance (written or oral) with your Plan within 1 year of the occurrence or file for a Medicaid Fair Hearing through DCF within 90 days of the occurrence. You should receive a notice of results by the Plan within 90 days of Plan receiving the grievance.
What can I do if have I have filed a grievance or an appeal with my Plan and I do not like the result?
You can file for a Medicaid Fair Hearing within 90 days of receiving your Plan’s notice of resolution or file another appeal with the Plan’s Beneficiary Assistance Program (BAP) with 1 year.
Who will assist me if I need to complain in any of these situations?
In almost all cases where there is a need to complain, you are dealing with protecting your legal rights. A qualified elder law attorney or an advocacy organization, such as the Foundation for LTC Solutions LLC, may be available to consult with you and your decision-maker on how best to proceed.
A conflict-free advocacy organization helping Florida’s elderly, their families and their providers obtain quality services within the new Florida Medicaid Managed Care system. The Foundation also offers consulting services to legal advocates and institutional care Providers to protect Florida’s seniors.