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800-1400: Florida Medicaid ESS Policy Manual

Below is a summary of chapters 800 and 1400 from the economic self sufficiency manual that medicaid agency caseworkers use to determine whether a medicaid applicant is eligible. This is not comprehensive and subject to change. This is only a summary of the sections I believe to be relevant to my practice as an elder law attorney.

Chapters 200, 400 and 600 from the Florida Medicaid Manual.

Chapter 1600 (Assets) from the Florida Medicaid Manual.

Chapter 1800 (Income) from Florida Medicaid Manual.

Chapter 2000, 2200, 2400, 2600 from Florida Medicaid Manual.

Chapter 800. Ongoing Case Processing.

0840.0500. Changes.  Any change (expected or unexpected) may affect eligibility or level of benefits.

Chapter 1400. Technical Requirements.

1440.0006.SSI-Related Technical Factors. Medicaid will consider the following factors:

1.      Citizenship/noncitizen status,

2.      SSN

3.      Residency

4.      Aged, blind/disabled

5.      Level of care / appropriate placement

6.      Living arrangement

7.      File for other benefits

8.      Receipt of other benefits

9.      Assignment of rights for 3rd party liability

10.  Medicare status, and

11.  Receipt of institutional, hospice or home and community based services.

1440.0007. Medicaid –Technical Factors for ICP.  Any Medicaid eligible individual applying for institutional care, HCBS or PACE services must meet the following requirements:

1.      Level of care / appropriate placement,

2.      Requirement to file for other benefits, and

3.      Transfer of asset provisions.

1440.0008. Additional Criteria – HCBS Waivers. Additional program criteria must be met depending on the Home and Community Based Waiver Program type as documented by Form CF-ES 2515 + Form CF-ES 2515 Instructions:

·        Statewide Managed Medical Care Long Term Care Waiver

·        Cystic Fibrosis Waiver

·        Familial Dysautonomia Waiver

·        iBudget Florida Waiver: for mentally disabled individuals.

·        Project AIDS Care

·        Traumatic Brain and Spinal Cord Injury Waiver

1440.0100, 1440.0101,1440.0102: All deal with US Citizenship Status.

1440.0103.Verification Sources for US Citizens. Individuals who receive SSI, any part of Medicare, SSDI based on work history are exempt from having to verify their citizenship. The following documents may be accepted to verify US citizenship:

·        US Passport (even if expired)

·        Certificate of Naturalization Form (DHS Form N-550 or N570)

·        Certificate of Citizenship (DHS Form N-560 or N-561)

·        Data from Driver’s and Vehicle Express (DAVE)system

·        Bureau of Vital Statistics Record if born in Florida

·        US birth certificate

·        Final Adoption Decree

·        Northern Mariana ID Card (I-873)

·        Official military record of service (e.g.DD-214)

If none of the above documents can be found, can use the following if they show a US place of birth dated 5 years prior to the Medicaid application:

·        Extract of hospital birth record on hospital letterhead (not souvenir birth certificate)

·        Life or health insurance record with a US place of birth

·        Early school record

·        Religious record (e.g. baptism, bris) within three months of birth.

1440.0104.Noncitizens. Certain non-citizens may qualify for Medicaid based on their status granted by US Citizenship and Immigration Services (USCIS).

1440.0105. Qualified Noncitizens. Those who meet at least one of the following sections of the Immigration and Nationality Act (INA):

1440.0106. Lawful Permanent Residents. An LPR is a noncitizen who lawfully immigrates to the US and has permission to live and work in the US and have lived in the US for at least five years. Proof of this status includes:

·        Resident alien card “green card” (I-551)

·        Reentry permit (I-327), or

·        Foreign passport with stamp stating “temporary evidence of lawful permanent resident status.”

1440.0106.01.Noncitizens Serving in US Military.

[ see requirements in manual ]

1440.0112. Cuban /Haitian Entrants.

·        USCIS Form I-94, stamped paroled as “Cuban/Haitian Entrant, Status Pending”

·        USCIS Form I-55I with code CU6 or CH6

1440.0200. Social Security Number. Must provide or verify that individual has applied for aSSN in order to be eligible for benefits.

1440.0303.01.Residency Requirements. Must reside in State of Florida with intent to remain. Provide proof:

·        State of Florida Driver’s License

·        State of Florida ID Card

·        Bank Statements

·        Utility Bill

·        Other reliable information

1440.0309. Residency Verification. If residency is questioned, it can be verified by a home visit, collateral contacts, rent/mortgage or utility receipts, other forms of ID,drivers’ license records, etc…

1440.0507. Age Requirements. For ICP program, there is no age requirement for those requiring skilled or intermediate care, institutional care benefits.

1440.1200. Aged, Blind or Disabled. Applicants must be aged, blind or disabled to be eligible for SSI-related Medicaid.

1440.1201. Aged Requirement. 65 or older.

1440.1204.Blindness/Disability Determinations. If individual has not already received a disability determination from SSA, a blindness/disability application must be submitted to the Division of Disability Determination (DDD) for those under age 65 who are requesting Community Medicaid under MEDS-AD, Medically needy…If SSA has already denied disability, Medicaid agent will use decision SSA has already rendered. BUT the Region or Circuit Medical Review Team (DMRT) handles all other necessary disability determinations (including ICP, OSS, ICP and PACE).

1440.1300. Appropriate Placement. To qualify for ICP or HSBC or PACE, individual must meet “appropriate placement” criteria – meaning they must be placed in a facility or program certified to provide the type and level of care DCF has determined is necessary. There are two basic requirements needed for placement to beconsidered appropriate:

·        Person must be determined by DCF to be medically in need of the type of care provided by the program; and

·        The person must be actually receiving the services (or for HCBS, must be enrolled in the waiver) which DCF has determined that the individual needs.

To be appropriately placed for ICP, a person must have been determined to be medically in need of an ICP level as determined by CARES and actually be placed in a Medicaid facility which provides the specified level of care.

For HCBS a person, to be appropriately placed, must be in need of waiver services and be enrolled in the waiver as documented by form CF-ES 2515 with an appropriate case manager.

1440.1302. Who Determines Need for Placement.

CARES(Comprehensive Assessment and Review for Long Term Care Services), Department of Elder Affairs:

·        For ICP: determines level of care for applicants over age 21 in nursing facilities, swing beds or hospital based nursing facility beds.

·        For HCBS: determines if Medicaid applicant meets waiver requirements.

·        For PACE: determines if the applicant meets the level of care.

1440.1303.Appropriate Placement for Institutional Care. Placement is appropriate when the individual is in a Medicaid facility certified to provide the level of care the individual requires. Applicants must require one of the following levels of care:

·        Skilled, Intermediate I, or Intermediate II in a nursing home or hospital swing bed’

·        One of four types of care (Level 6, 7, 8 or 9)

·        Appropriate care in a mental hospital for individuals age 65 and over.

1440.1304.Appropriate Placement for Hospice Services. Must have a medical diagnosis as terminally ill with life expectancy of 6 months or less if the illness runs its normal course.

1440.1305. Appropriate Placement for HCBS.  Individuals seeking alternatives to nursing home placement are considered for placement in the HCBS program. The following criteria must be met for an individual to be considered appropriately placed:

·        To be determined to meet a need for waiver services as evidenced by receipt of DOEA CARE Form 603 in case record (as determined by CARES), and

·        Be enrolled in a Medicaid waiver with an appropriate case manager as evidenced by a CF-ES 2515.

It is the HCBS case manager’s responsibility to request a level of care (LOC) for HCBS applicants.

1440.1307.Appropriate Placement for the OSS Program. The adult services counselor is responsible for evaluating the individual’s need for OSS placement in a facility most compatible with those needs. Placements are made in one of the following types of living arrangements:

·        Adult Family Care Homes;

·        Assisted Living Facility (ALF);

·        Home for Special Services; or

·        Mental Health Residential Treatment Facility

1440.1308 and 1440.1309 provide more information on OSS placement

1440.1310.Appropriate Placement for PACE.

1440.1400.Requirement to File for Other Benefits. Individuals must apply for and pursue an application for all other benefits for which they may be eligible(e.g. pensions, retirement benefits, disability, social security benefits,veterans benefits (aid and attendance, housebound allowance, etc…), military benefits, health and accident insurance payments, Medicare Part A, B, and D.

Individuals applying for SSI-related Medicaid must apply for Medicare if the state will pay the Medicare premium, deductible or coinsurance. They need not apply for SSI as a condition of eligibility.

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