Those who live at home or in the community but seek Florida Medicaid Managed Long-Term-Care coverage for Home and Community Based Services (HCBS).
The Florida Administrative Code Rules and Florida Statues explains 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 assigned 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’ screening, which is conducted per FAC Rule: 58A-1.010. Priority is determined by Florida Statutes, 409.979, per the priority score calculation methodology by DOEA.
The higher the score, the more frail the Medicaid applicant is deemed to be, which results in a higher priority placement on the waiting list.
Once DOEA has completed their screening, they will provide the applicant (or their authorized representative) 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, and instructions for how to request a re-screening should there be a significant change (i.e. deterioration) in their condition.
Medicaid Long-Term Care Waiver Program Priority Score Ranks
When CARES conducts it assessment, they asks the following questions:
CARES Caregiver 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
Overall health? How is their health compared to a year ago? What physical problems prevent Medicaid applicant from doing things that they would otherwise do? Can applicant get medical care when it is necessary? Are there financial limitations in obtaining necessary medical care?
Does Medicaid applicant have any problems with activities of daily living - ADLs (i.e. bathe, dress, eat, use bathroom, transfer, how much assistance needed to walk)?
Does the Medicaid applicant need assistance with what CARES refers to as “instrumental activities of daily living”: to handle heavy chores, light housekeeping, using the telephone, managing their money, preparing meals, shopping, managing their medications, and do they have access to transportation?
Each series of 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 services)
- Rank 7 = Imminent Risk (when an applicant in community is unable to care for themselves, has no access to a capable caregiver, AND they are likely to require nursing home care in the next 1-3 months). See Medicaid Attorney Resources section below for link to the actual questions and point value.
Once a Medicaid applicant has been released from the 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 services related to Title XIX (Medicaid).
409.965. All Medicaid recipients (subject to several exceptions) must receive their Medicaid 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 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 HCBS 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 Term Care 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.
409.983(4). CARES assigns the Medicaid recipient one of the following levels of care:
- Level 1: must be placed in 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.
409.985. CARES Program. CARES determines if individuals requires nursing facility care and if so assigns the level of care described in 409.983(4) above.
409.985(3)(a)-(c): “Nursing facility care” is defined.
Medicaid Lawyer Resources
Rule 59G-4.193 - How Florida Waiver / managed care priority works
Rule: 58A-1.010 – Program Forms