Part Deux on Florida s Move to Managed Care Countdown to the Managed Medical Assistance (MMA) FALA Mini-Conference USF Embassy Suites, Tampa May 20, 2014 Presentation by:
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Our Experts (3) Elder Law Experts Rebecca C. Bell, Port Richey, Florida Emma Hemness, Brandon, Florida Twyla Sketchley, Tallahassee, Florida As Advocates for Florida s Seniors, we continue to provide 1.Objective information; 2.Concise explanations; 3.Conflict-free advocacy. 1. Ongoing Education and alerts 2. Representation in grievances
Emma Hemness Law Office of Emma Hemness PA Brandon, Florida
Evolution **** Absorbsion *** Primary Purpose ** Important Reminders
In the beginning 2006: 5 County Pilot Project Mandatory enrollment No seniors 2011: Florida s Legislature passes pilot project expansion, plus Statewide mandatory enrollment, plus Seniors (all Medicaid recipients DD eligibles) 2013: CMS approves new Medicaid waiver 2018: CMS needs to approve renewal
Florida s Managed Care Programs Impacting Your Residents
LTC SMMC Absorbed March 1, 2o14 LTC rollout was completed in the last 3 regions Mandatory enrollment for all those on: Medicaid in the nursing home ALE Waiver ADA Waiver Diversion* * Psssstt. Diversion does not exist anymore.
As Medicaid Providers Your residents couldn t keep Medicaid coverage without being part of a network Managed Care Plans had to offer a contract ALF billing for Medicaid Waiver as of July 2012 Upon anniversary date Plans have authority to exclude ALFs for failing to meet performance & quality standards
What was a primary goal? Rebalancing Downhill Migration Moving residents into the home and/or community based settings, ie ALFs, from LTC facilities Goals set to move 35% from the NH; 2% in first year MCPs incentivized Bonuses (Achieved Savings Rebate) Capitated Payments Avoiding Uphill Migration Emphasizing case management, care coordination Providing services to support current setting
Important Rebalancing Reminders!
Protecting Yourself as a Medicaid Provider BEFORE you provide ANY services WHILE you are providing services AHCA has placed the responsibility on YOU! Your resident must be Medicaid eligible Your resident must be covered for those specific services you are rendering CHECKLIST: 1. Did you accurately check recipient eligibility? 2. Is the recipient currently enrolled in Managed Care? 3. Does the recipient have LTC coverage? 4. Is the recipient eligible for the date of service and the specific Medicaid service? 5. Do you have authorization from the LTC plan prior to rendering services? s 6. Did you document the verification of recipient eligibility?
Rebalancing Reminders (Cont d) Don t forget the big picture MCPs have financial incentives to rebalance Payments involves a higher rate for NH and lower rate for HCBS Plans must accept NH risk now In contrast to Diversion program Plans have final say on case management Yet, you must still follow the law for Residents Rights
Remember Your Role as an Advocate Why wait? Help your resident get on the waiting list! DOEA controls the list Call the ADRCs (gatekeeper) New 701S Form Telephone interview Priority Scoring/Frailty Ranking ALF residents are lower ranked Not immediate danger of institutionalization
Rebecca Bell, LL.M. Delzer, Coulter & Bell Port Richey, Florida
Issues/Glitch No. 1 Appropriate Notice/Due Process Issues Grievances/Appeals In writing?
When/How to File: A Reminder When there has been a denial, reduction, suspension or termination of services. Enrollee has 2 choices upon receipt of a Notice of Action 1. File an appeal with the Plan w/in 30 days OR 2. File a request for Fair Hearing with DCF w/ in 90 days
To continue services while waiting Enrollee must request an appeal with the Plan within 10 business days of the mailing date of the Notice or the intended effective date of the action, whichever is later. OR Request Fair Hearing within 10 days of the date of notice of action. KEY: Enrollee must request extension of benefits
Issues/Glitch No. 2 Deficiencies in Care Plan Process Authorized Rep not notified Family members not notified Pre-packaged Care Plan
Other Issues/Glitches Authorized representative not being recognized by Enrollment Broker (still ongoing frustration) AHCA form can only be signed by competent person Provided a copy of this form in our January presentation Will continue to be a headache in MMA selection Have the letter. Have the PIN number. Be prepared with multiple possible contact numbers, residency addresses, etc. If all else fails, ask for an in person meeting Occurrences of lock out of the designated rep. from online ACCESS after Medicaid is approved Upon Medicaid approval, LTC SMMC enrollment notices are either delayed or lost entirely Not getting sent to the designated rep. Loss of choice if there s no notices Delay in getting transition clients out of nursing home because selection is delayed.
Provider Complaints Plan should provide you Provider Handbook Includes policies and procedures for the Provider complaint system Plan s Toll-free Provider s Help Line Any aspect of a Plan s administrative functions, including proposed actions, claims, billing disputes, and service authorizations. NOTE: provider complaint system policies and procedures, including claims issues, to out-ofnetwork providers upon request.
Important Days to Remember 90 Days After Selecting a Plan To change your mind to another MCP If you change Plans, you get another 90 days Then, locked in until open enrollment Exception: good cause 60 Days Open Enrollment Prior to anniversary date NOTE: LTC open enrollments overlap with MMA rollout Example: June 1, 2014 Open Enrollment for LTC in Region 7 (60 days prior to August 1, 2013 of the initial roll-out) Ex: Regions 5 & 6 LTC Open enrollment would be December 1 All anniversary dates will reset to MMA roll-out dates Region 5 & 6 should be April 1, 2015 for LTC and MMA open enrollment Medicaid annual recertification dates do NOT change
Enrollment & the MMA SMMC Presentation later today by Melanie Brown-Woofter Statewide Director, Community Relations Agency for Health Care Administration Tallahassee, Florida Your residents must choose medical assistance plan now! Region 5 and Region 6 MMA Roll-out June 1 Most letters indicate a required selection by May 22 All LTC Plans are also MMA Plans (with one exception) Confusing for seniors Very little overlap of LTC/MMA Plans
Region 6 - (7) MMA Plans Which Plans are in Region 6? Amerigroup Florida Better Health Staywell Humana Medical Plan Integral Quality Care Prestige Health Choice Sunshine Health A,B,S,H,I, P, S spells Abs &. Hips
Region 5 (4) MMA Plans Which Plans are in Region 5? Staywell Prestige Amerigroup Sunshine Health S,P,A,S spells Spas
Overlap of Medicare & Medicaid Plans Medicaid is still payor of last resort! If Medicare covered medical service, then use Medicare service authorization procedures MMA is responsible for enrollee having a PCP either through Medicare or the MMA plan If non-medicare service (ie dentures), MMA plan responsible for authorizing Plan responsible for Medicare coinsurance, copayments and deductibles (MMA plan for MMA services & LTC plan for LTC services)
Overlap of LTC & MMA Services Assistive care services (LTC plan always pays ALF!) Case management (LTC case manager primary) Home health (LTC plan always pays) Hospice (LTC plan always pays) Durable medical equipment and supplies (LTC plan always pays) Therapy services (physical, occupational, respiratory, and speech-language pathology) (LTC plan always pays) Non-emergency transportation- see Transportation Service Requirements Snapshot under MMA tab
Step by Step For the Enrollee, prescriptions/pcp may be significant issue: 1.Choose a MMA MCP 2.Obtain a list of your prescriptions 3.Determine if pharmacy in network 1. If not, find another pharmacy 4.If do not have a current PCP, MCP will assign one 1. Enrollee can keep their Medicare approved PCP!
RED Flag Issues Not everything is easy to find Drugs must be on the Medicaid Preferred Drug list (Plans can choose to cover additional medications) Dosage limitations exist Link to list of drugs http://ahca.myflorida.com/medicaid/prescribed_drug/phar m_thera/fmpdl.shtml Link to dosage limitations http://ahca.myflorida.com/medicaid/prescribed_drug/pdf/s ummary_of_drug_limitations_3-31-2014_v04.pdf
Continuity of Care: Will you get paid or not? Same under LTC & MMA: Services/Treatments/Prescriptions must be provided/honored for up to 60 days & Providers paid NOTE: Different in LTC versus MMA: ONLY LTC plans provide coverage for 60 days during a loss of Medicaid eligibility (aid category SIXT ) ONLY LTC plans can provide services while Medicaid application is pending (aid category MEDP) Be careful to understand this distinction- Providers billing for non-ltc services will get denied!
Legislation affecting Florida s Seniors
2014 Medicaid Financial Criteria Florida s Income Standards Applicant s Countable Income (all non-exempt gross income) $2,163.00 income cap Veterans A&A benefits may be exempt Requires Income Cap Trust Legal document can only be created by certain persons DPOA must include special language+, eg. 10/1/2011 Excluded Income: PNA $35 and UME Community Spouse: All income is excluded Income can be raised if < $1938.75 monthly DCF Formula limits income Court Order can achieve higher amounts than formula Florida s Resource (Assets) Standards Countable Assets (all non-exempt assets) Applicant's Resource Allowance: $2000 in countable assets If income < $843: $5000 in countable assets. Community Spouse Resource Allowance: $117,240 Excluded Assets: - One vehicle less than 7 years of age - Multiple vehicles greater than 7 years of age - Irrevocable pre-need funeral arrangements - Burial plots for Applicant and immediate family - A primary residence (< $543,000 for Applicant) - Life insurance with the face/cash value: $2,500 Burial expense fund capped at $2,500 Personal effects and household goods Retirement accounts (only under special circumstances) Lookback & Penalties Apply to Gifts $7638 divisor applies to filings post 9/19/2013
Seniors Get a Raise! Medicaid ICP Personal Needs Allowance $35 since Moses came down from the Mount July 1, 2014: Raised to $100* per month! Provided the Governor does not line-item veto Veterans in State Veterans Nursing Homes ($105) Agreed upon by the FL Senate President & the FL Speaker of the House (and the world did not end) *This may be $105 also. TBD upon legislation being signed into law
Seniors Get More Transparency The mystery behind the Waiting List may get resolved Seniors do not understand priority or rank within DOEA controlled waiting list Appropriations legislation: Calls for rulemaking to establish criteria for HCBS waiting list (probably should have been part of the legislation a couple of years ago, but.) Confirms 60 day residency requirement for transition to HCBS
Florida Does Different Like Iowa Does Corn! House Bill 409 by Rep. Passadomo Helped by a Task Force of State Attorneys, Elder Law Attorneys, Law Enforcement & APS Investigators Passed unanimously in House and Senate [Who says nothing gets done during legislative session?]; and Adds more protections to Florida s elderly and disabled FL is the only state in the United States with a permissive presumption that allows a jury to presume you are an exploiter if Once a jury finds an exploiter guilty FL allows the perpetrator more quality time as a guest of the Florida Department of Corrections
You know you re an exploiter when The nice elderly person you just met gives you a big gift or a loan just because. Well, he wanted me to have it You take the nice elderly person s $$ merely by your powers of persuasion. I m like the son she never had er daughter? You don t have to put all that effort into coming up with good lies The nice elderly person makes you a joint account owner on her account and you take the $$$ Well my name was on it. Of course it s mine! That s what the bank teller said
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