As an elder law attorney, we often have to consult with the Florida Medicaid Policy Manual. This is a voluminous set of documents that is often updated and is what DCF case managers consult when processing and deciding whether or not to approve or reject a Medicaid application. Medicaid is an umbrella term that covers many programs. These summaries are not complete and are comprised of the sections that are the most relevant to my practice.
Chapter 200. General Program Information.
0240.0103. Eligibility Criteria. For all SSI-related programs, individual must meet the following criteria: age 65 or older, blind or disabled; US resident and citizen; Florida resident; SSN; file for all other benefits to which he may be entitled.
0240.0107. Institutional Care Program. For payment to nursing homes and other facilities (for aged and disabled who are in need of institutional care). All monthly income, except for a personal needs allowance (for the Medicaid applicant) and MMMNA (for community spouse) and a deduction for certain unreimbursed medical expenses, must be paid to the facility as the “patient responsibility.”
The ICP program applicant must meet all of the technical requirements as well as the following:
1. Income Limit: 300% of the Federal Benefit Rate (FBR) = $2,199.00
a. The FBR is the maximum monthly SSI payment. In 2016, the FBR is $733.00 per month
b. Those in excess may set up a qualified income trust (aka “Miller Trust").
2. Asset Limit: $2,000.00 per person (subject to the community resources allowance if there is a spouse living in the community); $3,000.00 per couple.
3. Must be in need of institutional care as determined by CARES (referred to as “level of care”).
4. Must be placed in a facility, certified by Medicaid, that is able to provide the level of care needed.
0240.0111. Home and Community Based Services (HCBS). Purpose of HCBS is to prevent institutionalization by providing care in the community. Following are the Medicaid waiver programs:
1. Cystic Fibrosis (CF);
2. Familia Dysautonomia (FD);
3. iBudget Florida Developmental Disabilities (DD);
4. Model Waiver;
5. Project AIDS Care (PAC);
6. Statewide Managed Medical Care Long Term Care (SMMC LTC); and
7. Traumatic Brain and Spinal Cord Injury (BSCIP)
0240.0117. Program for All Inclusive Care for the Elderly (PACE). Only available in certain areas. Designed to serve frail elderly in the home and community…includes acute and long-term care. Usually the comprehensive service allows them to continue living at home while receiving services rather than be institutionalized.
PACE is available to individuals who are 55 years old or older, and same asset/income limits as above.
0240.0118. Optional State Supplementation (OSS). This is a fully state funded, cash assistance program to supplement an individual’s income to help pay for community alternative living arrangements and preventing institutionalization.
0240.0119. Home Care for Disabled Adults (HCDA). This is a fully state funded program to encourage providing care for the disabled in a family-type living arrangement in private homes as alternative to institutional or nursing home care by providing a monthly support and maintenance payment to those providing the home care for the eligible disabled adult. Must be 60 years old older in addition to other criteria.
Chapter 400. Administrative Policy.
0440.0600. Fair Hearings. The Department of Children and Families must provide a fair hearing to any individual who disagrees with any decision, action or proposed action affecting the individual’s participation in the program.
0440.0602. Request for Fair Hearing. This is any clear expression (oral or written) by an applicant or their designated representative (within 90 days of DCF’s notice to the applicant of their decision). Supervisors must review hearing requests and provide a Department conference with the individual. The hearing request must be forwarded to the Office of Appeal Hearings within three business days.
0440.0604. Continuation of Benefits. If an individual requests a hearing by the end of the last day of the month prior to the effective date of the adverse action, DCF will reinstate the benefits to the prior level within 10 calendar days.
But benefit recipients are liable for any overpayment caused by the continuation of benefits pending the hearing decision.
0440.0606. Individual’s Hearing Rights. Right to review case record (and receive copies of same for free upon request) that will be used at the hearing.
0440.0607. Burden of Proof.
· On the individual, if first applying or seeking to increase benefits.
· On DCF, if it is reducing or terminating benefits.
The party with the burden of proof must meet a preponderance of the evidence standard.
0440.0608. Fair Hearing Decisions. A Final Order issued by the hearings officer is binding on DCF.
0440.0610. Reevaluating Medicaid Adverse Actions. A participant can request a reevaluation, for specific reasons, upon an adverse final order if such request is made within 90 days (if between 90 days and 12 months, only for good cause).
0440.0612. Community Spouse Resource Allowance. If an applicant is denied eligibility because of excess assets, a hearings officer may increase the CSRA to an amount that would generate income to bring the community spouse’s income up to the MMMNA.
During a fair hearing, when the spouse requests an increase in CSRA, the amount of resources adequate to provide the community spouse the MMMNA is based on the cost of a single premium lifetime annuity with monthly payments equal to the difference between the MMMNA and the amount of the community spouse’s income is expected to be when institutional care benefits are provided to the institutionalized spouse.
· The hearings officer must consider the community spouse’s actual income at the time of the fair hearing and any income that would be available from the institutionalized spouse upon approval of benefits, less income produced by the couple’s assets (all income sources should be considered before revising the CSRA).
Chapter 600. Application Processing.
0640.0400 Application Time Standards. Time standards begin upon receipt of a signed application. Applications should be processed within 90 calendar days for those claiming a disability. The a departmental delay occurs when application processing exceeds 90 days and the delay cannot be attributed to the applicant.
CARES Unit provides a level of care decision within 12 days of receipt of the request from the Department (who should submit the request within 2 days of receipt of application).
For ICP cases, an applicant can request a 30 day delay (need to be placed in facility to qualify).
[other time standards for requesting additional information and determinations of Medicaid eligibility are discussed here]
0640.0502. Date of Medicaid Entitlement. For those who are eligible, date of eligibility is first day of the month the application is received (regardless of when a decision is made). If someone is eligible for one day of any calendar month, the applicant is eligible for the entire month.
1. Eligibility for ICP cannot begin prior to the date of placement in a facility.
2. Eligibility for HCBS cannot become prior to the date the individual is enrolled in the waiver.
0640.0506. Months of ICP Eligibility. For ICP, the entitlement date is the first day of the month the individual is admitted to the facility (but the level of care determination must match placement on the date of admission).
0640.0509. Retroactive Medicaid. Medicaid is available for any one or more of the three calendar months preceding the application month, if:
1. Applicant has received Medicaid-reimbursable services during the retroactive period; and
2. Individual meets all eligibility factors during the months he/she requests retroactive Medicaid.