Long Term Care Managed Care Technical Advisory Workgroup Holds Inaugural Meeting to Review Process of Medicaid Eligibility

 

The Florida Agency for Health Care Administration’s Long Term Care Managed Care Technical Advisory Workgroup ("Workgroup") held its inaugural meeting on July 26, 2011, to discuss organizational issues, outline the Workgroup’s mission and establish future meeting dates.

Click here to access the agenda and meeting materials.

Established this year by the enactment of HB 7107, the Workgroup will assist in developing:

  1. The method of determining Medicaid eligibility pursuant to s. 409.985(3), F.S
  2. The requirements for provider payments to nursing homes under s. 409.983(6), F.S.
  3. The method for managing Medicare co-insurance crossover claims
  4. Uniform requirements for claims submissions and payments, including electronic funds transfers and claims  processing
  5. The process for enrollment of, and payment for individuals pending determination of their Medicaid eligibility

Elizabeth Dudek, Secretary for the Florida Agency for Health Care Administration ("AHCA"), opened the meeting, expressing her intention to attend future Workgroup meetings whenever possible.

"On behalf of the Agency and Governor, I would like to thank our agency partners, as well as agency staff in helping us go through something that will be somewhat unusual for this state.  We will need all of your thoughts and expertise to help us get through this and get it off the ground in the best way we can," Ms. Dudek said.

It was explained that the first meeting’s purpose was to convey an understanding of the Workgroup’s goals and objectives.  During the three-hour meeting, Workgroup members heard a variety of presentations on directives, the status of Florida’s Long Term Care Waiver, Florida’s Sunshine Law and legislative intent in forming the Workgroup.

AHCA Clerk Richard Shoop gave a presentation on the Sunshine Law, explaining that the Workgroup is subject to all aspects of it, and that meetings must be open to the public, minutes must be taken, and that reasonable notice of all meetings is required.

The Workgroup then reviewed elements of its charter, which included an outline of its responsibilities, membership, member term length, and scope of authority.

It was agreed that the 10-member Workgroup would need five members to constitute a quorum, but six members to take a final vote.  Workgroup members agreed that meeting only quarterly was inadequate, and that more meetings would be required.

"We have a lot of work ahead of us," one Workgroup member stated. 

Workgroup members also discussed how public comments might be managed, agreeing that they could be submitted in writing in advance.

The Workgroup was then directed to AHCA’s website at http://ahca.myflorida.com for a brief tutorial on navigating it.  It was explained that the Workgroup’s meeting agenda and meeting materials could be located by clicking a blue button within the site, which is labeled "Statewide Medicaid Managed Care" on the left side of the web page.

Another presenter gave a capsule summary of key implementation dates in Florida’s Statewide Medicaid Managed Care Program, which will commence in August 2011 and run through October 2014.

Beth Kidder, AHCA Bureau Chief for Medicaid Services, gave an overview of the program, explaining that House Bills 7107 and 7109 require AHCA to implement a statewide Medicaid Managed Care Program, consisting of a Managed Medical Assistance Program and a Long Term Care Managed Care Program.

Those eligible include persons 65 years or older who need a nursing care facility, and persons 18 years or older who are disabled and eligible for Medicaid and need a nursing care facility.

Those people who would enroll in the Long Term Managed Care Program include individuals who live in a nursing facility, and those enrolled in:  

  • Aged and Disabled Adult Waiver
  • Consumer-Directed Care Plus for individuals in the A/DA waiver
  • Adult Day Health Care Waiver
  • Assisted Living Waiver
  • Channeling Services for Frail Elders Waiver
  • Program of All-inclusive Care for the Elderly (PACE)
  • Nursing Home Diversion Waiver

The enrollment process includes:

  • A Florida Department of Elder Affairs’ Comprehensive Assessment and review for Long-Term Care Services ("CARES") to determine clinical eligibility
  • A CARES’ assessment to determine what services are needed. Consideration includes whether a nurse or other healthcare professional is the best choice for the patient, whether a physician agrees that the individual needs a nursing care facility, and whether the individual has any other way of receiving care in the community

Individuals have 30 days to choose one of the long term care plans, or be assigned to a plan.  Once enrolled, they have 90 days to choose a different plan, it was noted.

Workgroup members also heard a presentation on Medicaid Long Term Care Eligibility, with most discussion focusing on the assignment of a "level of care," which is a set of criteria developed by the state to determine who meets medical eligibility for institutional care programs.

Florida has three levels of care: 

  • Skilled services, which require 24-hour medical observation and care, with a registered nurse or other professional staff on hand
  • Intermediate care services ("level one"), which require the constant availability of medical and nursing treatment, and extensive health-related care due to mental or physical incapacitation
  • Intermediate care services ("level two"), which require constant availability of medical and nursing treatment, even though the individual needs limited health-care related care and service

"In addition to determining the level of care, we also make a placement recommendation," it was stated.  "We try to find the least restrictive placement.  We look at the availability of community and alternative services."

Workgroup members were then briefed on the complexities of enrolling in the program, and the related existing financial obligations.

After much discussion, the Workgroup agreed to hold its second meeting on August 26 and its third meeting on September 29.  With no further business before the Workgroup, the meeting was adjourned.

 

Should you have any comments or questions, please contact Colodny, Fass, Talenfeld, Karlinsky & Abate.

 

 

View Attorney Profile