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Applicant for Medicaid

Living in the Nursing Home

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This Section provides guidance for those who are not currently on Medicaid, yet are “ready to apply” for Medicaid services in the nursing home. Since the Medicaid program for nursing home coverage, known as Medicaid ICP, is an entitlement program, there is no waiting list as there are for persons who are applying for in home or assisted living facility services, known as HCBS. Anyone desiring to obtain nursing home Medicaid coverage must meet income and asset criteria and a level of medical need, and must also file an application.

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

 

How do I apply for Medicaid?

step_4_purpleThere are a number of programs of Medicaid for which an individual may apply (i.e. food stamps, medically needy, HCBS, etc.). In most programs, both financial eligibility and medical need are the criteria to be met.

For Medicaid ICP coverage, one must be 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.

You should obtain comprehensive guidance about Medicaid’s rules and procedures. 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.

In addition to financial eligibility, one must be determined to be a certain level of medical need. It is the Department of Elder Affairs (DOEA) CAREs office which will assess a nursing home resident’s medical need and issue a Level of Care (LOC).

After applying for Medicaid and getting my medical assessment, what is my next step?

step_4_purpleIt 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 sends you a letter introducing you to the statewide Medicaid Managed Care program. The State advises you that you must select a new Medicaid Managed Care Plan (Plan) which will oversee your care in the nursing home 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?

step_4_purpleYou do NOT have to select and enroll in a Plan until your application for financial approval for Medicaid ICP has been APPROVED. If you choose, you may make a “selection” of your desired Plan while you are pending financial approval, and this is known as a “pending choice”. You will NOT be able to fully enroll nor begin any services provided by the Plan while you are pending financial approval by the Department of Children & Families.

Who are the Plans that have been approved by the State and how do I select one?

step_4_purpleA 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.

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 as the regions in the state roll out. 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.”

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.

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

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

step_4_purpleAll 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.

What happens during the meeting with the Plan representative?

step_4_purpleAfter you have selected a Plan, 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 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 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?

step_4_purpleThe 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.

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.

What if I don’t believe I am receiving an adequate level of services from the Plan?

step_4_purpleIf 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.

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_4_purpleThe 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_4_purpleAfter 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_4_purpleThere 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 by the time the program is fully implemented in March 2014. 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.”

Will I have to move to a different nursing home?

step_4_purpleThe 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.

 

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