Health Care for Florida Children Cheat Sheet MEDICAID a/k/a State Plan Medicaid Eligibility by DCF Administered by AHCA Federal (about 58%); State (about 42%) Mandatory (every state must cover): Inpatient & Outpatient Hospital, Physician and Nurse Practitioner, Labs & X-rays, Prenatal care & Family Planning, EPSDT for under 21*, Nursing Homes, Rural Health Clinics, Federally Qualified Health Centers, Transportation. *EPDST has been interpreted to require states to offer ALL services, whether optional or mandatory, to children if they are medically necessary. Optional (states can chose to cover): HCBA, Pediatric Nursing Facilities, Inpatient Psychiatric for under 21, ICF/DD, Prescription meds, personal care services, Therapies (PT/OT/ST/RT), vision & dental services, durable medical equipment Eligibility: Age: Depends on category Categories of eligible individuals: Children (under age 21), Pregnant women, Adults with dependent children, Anyone getting SSI, Elderly, Blind or Disabled Financial: It s complicated, but a child will qualify for any of these reasons: 1. Gets SSI, which requires a finding of disability and very low household income and assets 2. Birth to 1 with household income less than or equal to 200% FPL 3. Age 1 to 21 with household income less than or equal to 138% FPL 4. Is a dependent of the state; (also, if under 26 and aged out of foster care, and getting Medicaid when aged out; no income/asset test) 5. Is covered as part of an adoption assistance subsidy; 6. Is enrolled in a Waiver program (child is treated as a household of one for income and asset criteria.) Enrollment Process: Apply through DCF Service Center (online ACCESS), KidCare (including MediKids and HealthyKids), or the ACA Insurance Exchange Statutory Authority: Federal: Title XIX of the SSA (42 USC 1396 et seq.) State: Chapter 409, Fla. Stat. Rules: Federal: 42 CFR 430 et seq. See 42 C.F.R. 441.50-.62 for EPSDT State: Chapter 65A, F.A.C.
Handbooks: Handbooks are adopted as rules through AHCA for Medicaid services, provider requirements, and most Medicaid Waiver programs.they can be found online at AHCA s website under Provider Support/Provider Handbooks: http://portal.flmmis.com/flpublic/provider_providersupport/provider_providersupport_provid erhandbooks/tabid/42/default.aspx Useful examples include: Medicaid Summary of Services, Medicaid Home Health Services, Child Health Check-Up (formerly EPSDT). Waiting List: None. Medicaid is an entitlement for anyone who is eligible. MEDICALLY NEEDY MEDICAID Eligibility by DCF Administered by AHCA Same as State Plan Medicaid Same as State Plan Medicaid, except not nursing home care. Also not applicable to Waivers Eligibility: Clinical: Individual is eligible for Medicaid under any eligibility category but does not meet financial criteria. Enrollment is determined monthly based on Share of Cost. Financial: Share of Cost is determined based on household Modified Adjusted Gross Income, less about $250 per dependent. For Medicaid to kick in, bills from Medicaid providers must be submitted to DCF in an amount equal to or greater than the Share of Cost. For the remainder of the month, the eligible individuals are covered by Medicaid. Enrollment Process: Same as Medicaid. Plus, DCF is supposed to determine eligibility any time another type of Medicaid is terminated. Statutory Authority: State: 409.904(2), F.S. Rules: Federal: 42 CFR 435, Subpart D State: See F.A.C. Rules 65A-1.702, 1,713 Handbook: See Medicaid Provider Reimbursement Handbook CMS-1500 Claim Form (Special billing for Medically Needy Recipients) Waiting List: None
MEDIKIDS (A KidCare CHIP Program) Eligibility through KidCare/HealthyKids Administered by AHCA Federal (about 70%); State (about 30%), but there is a federal cap Same as State Plan Medicaid, including EPSDT. This program is, essentially, an extension of Medicaid. Eligibility: Age: 1 through 4 Other: Uninsured, citizen or qualified non-citizen, not eligible for Medicaid, not in an institution Financial: Modified Adjusted Gross Income of household less than 200% of FPL. Requires small premium payment of $15 or $20 per month. MediKids is available for a full pay premium (under $200/month) either for uninsured or underinsured children. Enrollment Process: Same as Medicaid. Also, DCF is supposed to submit a KidCare application if Medicaid is terminated. Statutory Authority: Federal: Title XXI of SSA State: KidCare 409.810, et seq ; MediKids 409.8132, F.S. Rules: Federal: 42 C.F.R. Chapter IV, Subchapter D State: KidCare Grievance Process at Chapter 59G-14 Handbook: Same service requirements as Medicaid, so look at Medicaid Handbooks Waiting List: None currently, but CHIP is not an entitlement like Medicaid. The state can stop enrollment or modify benefits. HEALTHYKIDS (A KidCare CHIP Program) Eligibility through KidCare/HealthyKids Administered by HealthyKids Federal (about 70%); State (about 30%), but there is a federal cap
Benefit package similar to insurance, with minimum benefits set out in 409.815(2), F.S. Not as extensive as MediKids/Medicaid. Availability of home health services is unclear. Eligibility: Age: 5 through 18 Other: Uninsured, citizen or qualified non-citizen, not eligible for Medicaid, not in an institution Financial: Modified Adjusted Gross Income of household less than 200% of FPL. Requires small premium payment of $15 or $20 per month. HealthyKids is available for a full pay premium (under $200/month) either for uninsured or underinsured children. Enrollment Process: Same as Medicaid. Also, DCF is supposed to submit a KidCare application if Medicaid is terminated. Statutory Authority: Federal: Title XXI of SSA State: KidCare 409.810, et seq.; Benefits 409.815, F.S. Rules: Federal: 42 C.F.R. Chapter IV, Subchapter D State: KidCare Grievance Process at Chapter 59G-14 Handbook: Member handbook of organization administering claims, like United Healthcare Waiting List: None currently, but CHIP is not an entitlement like Medicaid. The state can stop enrollment or modify benefits. CHILDREN S MEDICAL SERVICES Clinical eligibility through Department of Health Financial eligibility through either DCF or HealthyKids CMS Network (both Medicaid and SCHIP enrollees) administered by Department of Health Medicaid, CHIP, and federal Title V Maternal & Child Health Block Grant Same as State Plan Medicaid, along with case management services and an expanded provider network of medical, therapeutic and support services. Moving to Managed Care in August of 2014. Eligibility: Age: Birth to 21
Clinical: Medically complex Financial: Same as Medicaid or CHIP programs, but no full pay option (Note: the lack of a full pay option is under court challenge.) Enrollment Process: Same as Medicaid and CHIP, but requires a clinical assessment by CMS nurses. Statutory Authority: Federal: See funding State: Chapter 391 Rules: Federal: Depends on program eligibility State: F.A.C. Chapter 64C Handbook: CMS Provider Handbooks for Physicians & Dentists, Licensed Non-Physician Healthcare Professionals, Non-Licensed Healthcare Professionals at CMS website. Waiting List: None currently, but if CHIP is the eligible program, it is not an entitlement like Medicaid. The state can stop enrollment or modify benefits for CHIP. BIRTH-RELATED NEUROLOGICAL INJURY COMPENSATION ASSOCIATION PROGRAM (NICA) Department of Financial Services State, but may be offset by other insurance sources, including Medicaid Wide range of medical, therapy and care benefits, but waiver of any other malpractice compensation Eligibility: Age: Lifetime coverage if eligible, but claim must be filed by child s 5 th birthday Clinical: Oxygen deprived or mechanical injury in labor or delivery or resuscitation immediately post-delivery; Permanent, substantial mental and physical impairment Financial: None Enrollment Process: Must file petition with DOAH for an eligibility determination by an Administrative Law Judge. Statute of limitations for medical malpractice applies but is tolled by administrative claim.
Statutory Authority: State: 766.301-766.316, F.S. Handbook: Benefit Handbook at NICA website EARLY STEPS Department of Health/CMS Federal (through IDEA and Medicaid) and State Intervention to address developmental delays and promote learning; developed through an Individual Family Support Plan Eligibility: Age: Birth to 36 months Clinical: in delays Significant delay or established medical condition likely to result Financial: None, but can receive services under Medicaid, if eligible Enrollment Process: Referral to contracted regional Early Steps office, usually by a health care provider, but parent can call as well. Statutory Authority: Federal: Title XIX of SSA (Medicaid) and Part C of IDEA State: 391.301 et seq. and Ch. 393. Rules: Federal: 42 CFR 430 et seq. See 42 C.F.R. 441.50-.62 for EPSDT and 34 CFR 300, et seq. State: 59G-4.085 (Handbook); 6A-6.03030 (ESE Eligibility for Infants or Toddlers Birth Through Two Years Old who have Established Conditions); 6A-6.03031 (ESE Eligibility for Infants and Toddlers Birth Through Two Years Old who are Developmentally Delayed); 6A- 6.0361 (Contractual Agreements With Nonpublic Schools and Residential Facilities); 6A-6.0331 (General Education Intervention Procedures, Evaluation, Determination of Eligibility, Reevaluation and the Provision of ESE Services); 64F-3.004 Healthy Start Care Coordination System. Handbook: Medicaid Early Intervention Services Waiting List: None
MEDICAL FOSTER CARE Coordination with AHCA, CMS (DOH), DCF Child Welfare and Community- Based Care Program Federal and State. DCF reimburses for room, board, and living expenses. Medicaid reimburses for medically necessary care, such as assisting with activities of daily living, administering medication, changing dressing. Foster home with trained providers, oversight by social worker, nurse, training of family if re-unification. Services will depend on the level of need. Eligibility: Age: Birth to 21 Clinical: Financial: Medically complex, but medically stable in home setting In custody of DCF Enrollment Process: Placement recommended by CMS (CMAT); Placement approval by DCF and CMS physician; Authorization from service authorization nurse at AHCA Area Office Statutory Authority: Federal: Title XIX and V of SSA State: Chapter 409, F.S. (related to foster care, generally) Rules: State: F.A.C. Chapters 65C-12 (Emergency Shelter); 65C-13 (Substitute Care of Children), Rule 59G-4.197 (Medicaid Summary of Services Handbook) Waiting List: Depends on availability of Medical Foster Care home THE MEDICAID WAIVER PROGRAMS DEVELOPMENTAL DISABILITIES ibudget WAIVER Clinical eligibility determined by Agency for Persons with Disability Financial eligibility determined by DCF Administered by APD. AHCA is the designated single-state agency for Medicaid Same as Medicaid Home and community-based services, including personal support and respite, services that provide a meaningful day activity (e.g., adult day training),
consumable medical supplies (e.g., diapers), durable medical equipment (e.g., a wheelchair), behavioral and mental health services, OT, PT, ST, RT, and environmental modifications, among others. Eligibility: Age: 3 and up Clinical: 1. Diagnosed with one of six different developmental disabilities that occurred before the age of 18: mental retardation (IQ of 59 or less, or between 60 and 69 with a handicapping condition), cerebral palsy, autism (not Asperger s or PDD-NOS), spina bifida, Prader- Willi Syndrome or Down Syndrome; and 2. Has substantial limitations in at least three life activities: self-care, learning, mobility, self-direction, understanding and use of language, and capacity for independent living. Financial: The individual with developmental disability is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Apply for eligibility through Regional APD Office Statutory Authority: Federal: 1915(c) of SSA (42 U.S.C. 1396n) State: Chapter 393, F.S. Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Chapter 65G Handbook: Developmental Disabilities Home and Community-Based Services Coverage and Limitations Handbook. (A new Handbook for APD s ibudget Program has been proposed.) Enrollment: 29,082 Waiting List: 22,069* [Footnote: all figures for enrollment and waitlist based on 2013 OPPAGA Report] Priority for Waiting List: Crisis enrollment rules (F.A.C. 65G- 1.047) allow for a crisis application. If approved, individual moves to top of list. Denial allows fair hearing challenge. FAMILIAL DYSAUTONOMIA WAIVER Clinical eligibility determined by AHCA
Financial eligibility determined by DCF Administered by AHCA AHCA is the designated single-state agency for Medicaid Same as Medicaid Case management, respite, consumable medical supplies, durable medical equipment, behavioral services, non-residential support services, dental services. Eligibility: Age: 3 and up Clinical: level of care. Diagnosis of familial dysautonomia. Requires inpatient hospital Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Apply for eligibility through AHCA Statutory Authority: 1915(c) of SSA (42 U.S.C. 1396n) Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Rule 59G-13.102 Enrollment: 8 Waiting List: None Priority for Waiting List: Prioritization based on scores of fragility assessment. ADULT CYSTIC FIBROSIS WAIVER Clinical eligibility determined by DOEA (CARES assessment) Financial eligibility determined by DCF Administered by DOH Same as Medicaid Chore, case manager, counseling (individual and family), dental, home-delivered meals, homemaker, massage therapy, nutritional supplements, personal care, PERS, PT, medication, RT, respite, skilled nursing, specialized medical equipment and supplies Eligibility: Age: 18 and up
Clinical: Diagnosed with Cystic Fibrosis by a physician. At risk of hospitalization Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Apply for eligibility through DOH Brain and Spinal Cord Injury Central Registry (1-800-342-0778) or online at BSCIP website Statutory Authority: Federal: 1915(c) of SSA (42 U.S.C. 1396n) Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Rule 59G-13.015 Enrollment 110 Waiting List: None MODEL WAIVER Clinical eligibility determined by CMS Financial eligibility determined by DCF Administered by AHCA Same as Medicaid Assistive technology, case management by CMS, environmental accessibility adaptations, nursing home transition, respite (other home health services covered by Medicaid) Eligibility: Age: Up to age 20 Clinical: Diagnosed with degenerative spinocerebellar disease by a physician; Medically complex or medically fragile; At risk of hospitalization as determined by Children s Multidisciplinary Assessment Team (CMAT) Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Apply for eligibility through AHCA, Level of care assessment through CMS (CMAT). Statutory Authority: Federal: 1915(c) of SSA (42 U.S.C. 1396n)
Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Rule 59G-13.080 Enrollment: 5 Waiting List: 3 Priority for Waiting List: Prioritization based on scores of fragility assessment. PROJECT AIDS CARE (PAC) WAIVER Clinical eligibility determined by DOEA (CARES assessment) Financial eligibility determined by DCF Administered by AHCA Same as Medicaid Case management, chore, day health care, education and support, environmental accessibility adaptations, home-delivered meals, homemaker, personal care, restorative message, skilled nursing, specialized medical equipment and supplies, specialized personal care for children in foster care, therapeutic management of substance abuse Eligibility: Age: No age criteria Clinical: Diagnosed with AIDS by physician; Presence of AIDS-related opportunistic infection; At risk of institutionalization (CARES assessment); Disabled by SSA standards Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Apply for eligibility through AHCA Statutory Authority: Federal: 1915(c) of SSA (42 U.S.C. 1396n) Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Rule 59G-13.110 Handbook:Project AIDS Care Waiver Services Enrollment: 6,844 Waiting List: None
TRAUMATIC BRAIN INJURY/SPINAL CORD INJURY (TBI/SCI) WAIVERS Clinical eligibility determined by DOEA (CARES assessment) Financial eligibility determined by DCF Administered by DOH Same as Medicaid Assistive technology, attendant (nursing) care (limited to 3 hours/day), behavioral, case management, companion, CMS, PER, environmental adaptations, life skills training, OT, PT, ST, RT, counseling, rehab engineering eval, res hab Eligibility: Age: 18 or older Clinical: Diagnosed with traumatic brain or spinal cord injury, defined in 381.745, F.S.; Medically stable; Level II level of care for nursing home (CARES assessment); Referred to Brain and Spinal Cord Injury Program (BSCIP) Central Registry Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Contact DOH s BSCIP Central Registry (1-800-342-0778) or online at the BSCIP website Statutory Authority: Federal: 1915(c) of SSA (42 U.S.C. 1396n) State: 381.7395 -.76 Rules: Federal: 42 C.F.R. 441.300 et seq. State: F.A.C. Rule 59G-13.130 and.131 Handbook: TBI/SBI Waivers Coverage and Limitations Handbook Enrollment: 286 Waiting List:309 Priority for Waiting List: Prioritization based on scores of fragility assessment. LONG TERM CARE PROGRAM WAIVER Clinical eligibility/priority determined by DOEA (CARES assessment)
Financial eligibility determined by DCF Administered by AHCA through private managed care organizations (MCOs) through the state. Same as Medicaid; MCOs are funded on a capitated rate Case management, companion, adult day health care, assisted living, attendant (nursing) care, behavioral, home accessibility, home-delivered meals, homemaker, hospice, skilled nursing, DME, medication administration and management, nursing facility, personal care, PERS, Respite, OT, PT, ST, RT, transportation Eligibility: Age: 18 or older Clinical: Disabled, as defined by SSA; Level of care for institutionalization (CARES assessment); Individuals already enrolled in the following waivers: Aged and Disabled Adult, Channeling for Frail Elders, Assisted Living, Nursing Home Diversion. Financial: The individual is treated as a separate household, so only his or her income/assets are considered. Same criteria as Medicaid for Institutional Care Placement. Enrollment Process: Contact AHCA or the Aging and Disability Resource Center in your area Statutory Authority: Federal: 1915(b) of SSA (42 U.S.C. 1396u-2) and 1915(c) of SSA (42 U.S.C. 1396n) State: Chapter 409, Part IV, F.S. Rules: Federal: 42 C.F.R. Part 438 State: F.A.C. Rule 59G-13.130 and.131 Handbook: Member benefit handbook for the individual MCO Enrollment: Over 85,000 Waiting List: 34,559 Priority for Waiting List: Prioritization based on scores of fragility assessment. DOEA is managing the waiting list. Rules authorized by 2014 Legislature but not yet developed.