Medicaid Waiver Waitlist and Priority Scores in Florida
Navigating the Medicaid waiver waitlist in Florida can be a complex process, and understanding priority scores is essential to receiving the care you need. Priority scores determine the order in which individuals receive Medicaid services, and being on the waitlist doesn't guarantee access to services.
A Florida Medicaid planning lawyer can help you explore how the Medicaid waiver waitlist works in Florida, how priority scores are calculated, and how you can increase your chances of receiving services.
How Does the Medicaid Waiver Process Work?
The Florida Administrative Code Rules and state statutes explain how people who apply to the Florida Statewide Medicaid Managed Care Long-Term-Care Waiver Program are prioritized and enrolled.
Applicants are given a priority rank based on their priority score, which signifies the assessed need for long-term care services and determines placement on the HCBS wait list (maintained by the Department of Elder Affairs).
The priority score is provided by the Department of Elder Affairs’ (DOEA’s) screening, conducted per FAC Rule: 58A-1.010. Priority is determined by Florida Statutes, 409.979, per the priority score calculation methodology by DOEA.
Once DOEA has completed their screening, they will provide the applicant (or their authorized representative) with:
- Notification of the Medicaid applicant’s priority rank
- Where this places them on the waiting list
- How to get in touch with a local ADRC
- How to request a fair hearing if they feel an error has occurred
- How to request a copy of their screening/priority score
- Instructions for how to request a re-screening should there be a significant change (i.e., deterioration) in their physical health condition
Florida Medicaid Waiver Program Priority Score Ranks
When CARES conducts its assessment, it asks the following questions.
CARES Caregiver Medicaid Waiver Screening Questions
- Is there a primary caregiver?
- If not, who does the applicant live with? (Living alone assigns higher priority points.)
- If there is a primary caregiver, how is the caregiver’s health in relation to their ability to provide care to the applicant?
- How confident is the caregiver in their ability to continue to provide care in the future?
CARES Medicaid Applicant Questions
- What is their overall health?
- How is their health compared to a year ago?
- What physical problems prevent Medicaid applicants from doing things they would otherwise do?
- Can applicants get medical care when it is necessary?
- Are there financial limitations in obtaining necessary medical care?
- Does the Medicaid applicant have any problems with activities of daily living (i.e., bathe, dress, eat, use the bathroom, transfer, how much assistance is needed to walk)?
- Does the Medicaid applicant need assistance with what CARES refers to as “instrumental activities of daily living”?
- Handling heavy chores or light housekeeping
- Using the telephone
- Managing their money
- Preparing meals
- Managing their medications
- Do they have access to transportation?
Each series of Medicaid waitlist screening questions has a point scale associated with the answer. The points are added up to assign a priority rank:
- Rank 1 = Score 1-15
- Rank 2 = Score 16-29
- Rank 3 = Score 30-39
- Rank 4 = Score 40-45
- Rank 5 = >46
- Rank 6 = (when a minor is aging out, but still needs
- Rank 7 = Imminent Risk (when an applicant in the community is unable to care for themselves, has no access to a capable caregiver, AND they are likely to require care in a nursing home or assisted living facility in the next 1-3 months). See Medicaid Attorney Resources section below for the link to the actual questions and point value.
Nursing home residents in a Florida-licensed nursing facility for at least 60 consecutive days are exempt from screening.
Once a Medicaid applicant has been released from the waiver waitlist, the Agency for Health Care Administration (AHCA) will enroll them into a long-term care managed care program in their area.
Medicaid Managed Care and Long Term Care Managed Care Program
Florida Statues, Chapter 409, Part IV (409.961 – 409.985) governs the Medicaid Managed Care and Medicaid Long Term Care Managed Care Program:
- 409.963. Agency for Health Care Administration is the state agency authorized to manage, operate and make payments for medical assistance for TitleXIX (Medicaid) services.
- 409.965. All Medicaid recipients (subject to several exceptions) must receive their services through a managed care program.
- 409.966(2). Sets forth the Medicaid regions. (J) Region 10 is Broward County. (K) Region 11 is Miami-Dade and Monroe Counties.
- Most of Part IV sets forth the requirements for plans, what accreditation they must have, what minimum standards they must meet, etc.
- 409.969. Sets forth when Medicaid recipients must enroll in a managed care plan (30 days, followed by 90 days in which to dis-enroll and find another plan, after 90 days, “good cause” must be shown to switch plans).
- 409.973. Sets forth minimum benefits that managed care plans must offer.
- 409.978. Long-Term Care Managed Care Program.
- 409.979. Eligibility — 65+ years old or 18 years old with a disability. Must go through Comprehensive Assessment Review and Evaluation for Long-Term Care Services (CARES) screening program to determine that nursing facility care is required (see 409.985(3)). Subject to the availability of funds, the Department of Elderly Affairs (DOEA) makes offers for enrollment subject to wait-list prioritization. The DOEA maintains the statewide list for enrollment for Home and Community Based Medicaid services through the LTC-MCP (long-term care managed care program). DOEA authorizes aging resource centers to screen individuals requesting HCBS through the LTC program.
- 409.98. Long TermCare Plan Minimum Benefits. Nursing facility care, some ALF services, hospice, adult day care, medical equipment, supplies, incontinence supplies, personal care, home accessibility adaptation, behavioral management,home-delivered meals, case management, OT, PT, ST, RT, intermittent nursing, skilled nursing, medication management, nutritional assessment, caregiver training, respite care, transportation, personal emergency response system. Click here for a more in-depth discussion of What does Florida Medicaid Waiver Cover?
- 409.983(4). CARES assigns the Medicaid recipient one of the following levels of care:
- Level 1: Must be placed in a nursing home
- Level 2: Imminent risk of nursing home placement(need for constant availability of routine medical and nursing treatment and who require extensive health-related care and services because of mental or physical incapacity.
- Level 3: Imminent risk of nursing home placement(need for constant availability of routine medical and nursing treatment and who have a limited need for health-related care and are mildly mentally or physically incapacitated.
Need Help Navigating the Medicaid Waiver Process?
The Medicaid waiver waitlist and priority scores can be challenging to navigate, but with the help of an experienced elder law attorney, you can increase your chances of receiving the care you need. An attorney can guide you through the application process, help you understand priority score calculations, and advocate for you to ensure you receive the services you need.
Don't hesitate to contact our team at Elder Needs Law for assistance if you have any questions or concerns about Medicaid in Florida.