Florida s Statewide Medicaid Managed Care Program Patient Responsibility for Long-term Care Enrollees Residing in Assisted Living Facilities November 16, 2016
What is patient responsibility? The cost of Medicaid long-term care services not paid for by the Medicaid program, for which the enrollee is responsible. Patient responsibility is the amount enrollees must contribute toward the cost of their care. The amount of patient responsibility is determined by the Department of Children and Families (DCF) and is based on income and choice of residence. SMMC Core Contract, Attachment II, Section 1.A, Effective 8/15/16 SMMC Model Contract accessible at this Web site: http://ahca.myflorida.com/medicaid/statewide_mc/plans.shtml. 2
Is patient responsibility required of enrollees in Medicaid Home and Community-Based Services (HCBS) waivers? Yes. Medicaid must reduce payments for HCBS provided under the Statewide Medicaid Managed Care (SMMC) Long-term Care (LTC) waiver, by the amount of the enrollee s patient responsibility, in compliance with: Title 42, Section 435.726, Code of Federal Regulations; & Section 2404 of the Affordable Care Act. This includes residents in assisted living facilities (ALFs). 3
What entity determines the amount of patient responsibility for the SMMC LTC enrollee? The Department of Children and Families (DCF) is the only entity that can determine the amount of patient responsibility for an SMMC LTC enrollee. 4
Can DCF determine the amount of patient responsibility to be a zero dollar value? Yes. DCF may determine the amount of the patient responsibility to be a zero-dollar value. 5
How does DCF determine the amount of patient responsibility for an SMMC LTC enrollee residing in an ALF? DCF determines the amount of patient responsibility for SMMC LTC enrollees residing in an ALF through the post-eligibility treatment of income process, according to the requirements in: Chapter 65A-1.7141, Florida Administrative Code; and Title 42 Section 435.725, Code of Federal Regulations. 6
What are the key components of patient responsibility when the SMMC LTC enrollee resides in an ALF? When the SMMC LTC enrollee resides in an ALF, the key components of patient responsibility are the amount of the: enrollee s income; personal needs allowance (PNA); and uncovered medical expense deductions (UMEDs). 7
What is a personal needs allowance (PNA)? A personal needs allowance (PNA) is the amount of monthly income DCF calculates that the SMMC LTC enrollee may keep to pay for personal expenses. 8
How does DCF compute the personal needs allowance (PNA) for the SMMC LTC enrollee residing in ALF? DCF computes the personal needs allowance (PNA) by taking the monthly amount of the basic room and board that the enrollee s ALF charges, and adding 20% of the current year s Federal Poverty Level (FPL). 9
This is an example of how DCF would calculate the personal needs allowance (PNA) of an SMMC LTC enrollee residing in an ALF in 2016, when they have a monthly ALF basic room & board charge of $1,500. $1,500 Monthly ALF basic room and board charges $ 198 20% of the 2016 Federal Poverty Level (FPL) $1,698 Personal Needs Allowance 10
Does DCF compute the personal needs allowance (PNA) differently if the SMMC LTC enrollee resides in a nursing facility or in an ALF? Yes. DCF computes the amount of the personal needs allowance (PNA) differently based on the type of residence. During the time the SMMC LTC enrollee resides in a nursing facility, the PNA is $105.00. (*Chapter 65A-1.7141, Florida Administrative Code) During the time the SMMC LTC enrollee resides in an ALF, DCF computes the PNA by taking the monthly amount of the basic room and board that the enrollee s ALF charges, and adding 20% of the current year s Federal Poverty Level (FPL). (*Chapter 65A-1.7141, Florida Administrative Code) 11
How can the SMMC LTC enrollee residing in ALF spend their personal needs allowance (PNA)? The SMMC LTC enrollee may use the PNA to pay for the ALF s monthly basic room and board charges, and cover personal expenses for items such as shoes, clothing, and magazines. 12
How does DCF use the personal needs allowance (PNA) to calculate patient responsibility for an SMMC LTC enrollee that resides in an ALF? To calculate patient responsibility for an SMMC LTC enrollee that resides in an ALF, DCF reduces their total gross income by the amount of their personal needs allowance. 13
This is an example of how in 2016, DCF would calculate patient responsibility for an SMMC LTC enrollee that resides in an ALF, has an Social Security Income (SSI) income of $1,750; a monthly ALF basic room & board charge of $1,500; and no uncovered medical expense deductions (UMEDs). $1,750 Monthly Social Security Income (SSI) -$1,500 Monthly ALF basic room and board charges -$ 198 20% of the 2016 Federal Poverty Level (FPL) - 0 Uncovered Medical Expense Deductions (UMEDs) $ 52 Monthly Patient responsibility *PNA *PNA: Personal Needs Allowance 14
How does DCF know the amount of the ALF s basic room and board charges per month? The ALF must provide DCF with documentation of the amount of the facility s basic room and board charges per month. The amount of the facility s basic room and board charges covers three meals per day and a semi-private room. The amount of the facility s basic room and board charges does not cover charges for any goods or services beyond three meals per day and a semi-private room. 15
What will DCF accept as documentation of the facility s basic room and board charges? As documentation of the facility s basic room and board charges per month, DCF will accept a letter from the ALF that: is written on the ALF s official letterhead; and provides all of the information in the next two slides. (continued on next page) 16
Documentation from ALF must include: 1. ALF s business name, street address with city, state, and zip code, telephone number, and fax number; 2. Date the letter was written; 3. ALF resident s name (first name, middle initial and last name); 4. ALF resident s date of birth (include month, day and year); 5. ALF resident s Social Security Number or DCF Access Number; 6. Date of admission to the ALF (include month, day and year); (continued on next page) 17
Documentation from ALF must include: 7. ALF s basic room and board rate for the provision of three meals per day and semi-private room per month (dollar value); 8. Contact information for the individual to whom DCF can address any questions (first and last name, job title, and telephone number with the area code); 9. Signature (of person authorized to provide this information) along with: Date letter signed (include month, day and year); Printed first and last name person authorized to provide this information; and Printed job title of person authorized to provide this information. 18
Can the enrollee provide DCF with the ALF s documentation? Yes. Enrollees may submit the ALF s documentation to DCF by: uploading files online to MyACCESS Account; or faxing documentation to 1-866-886-4342; or mailing documentation to the: ACCESS Central Mail Center PO Box 1770 Ocala, FL 34478-1770 19
Can the ALF provide DCF with the ALF s documentation? Yes. On behalf of the SMMC LTC enrollee, the ALF may submit the ALF s documentation to DCF by either: faxing documentation to 1-866-886-4342; or mailing documentation to: ACCESS Central Mail Center PO Box 1770 Ocala, FL 34478-1770 20
Can the SMMC LTC plan provide DCF with the ALF s documentation? Yes. The SMMC LTC plan s case manager may submit the ALF s documentation to DCF as an attachment to a completed DCF form CF-ES 2515, Certification of Enrollment Status Home and Community Based Services (HCBS). DCF forms are accessible on this DCF Web site: http://www.dcf.state.fl.us/dcfforms/search/dcfformsearch. aspx. 21
Can DCF change the monthly amount of patient responsibility? Yes. DCF can change the monthly amount of patient responsibility for one or more months. For instance DCF may determine: an increase in the amount of the enrollee s patient responsibility due to an increase in the enrollee s income; or a decrease in the amount of the enrollee s patient responsibility due to a DCF approved uncovered medical expense deduction (UMED). 22
What is an uncovered medical expense? An uncovered medical expense may occur when the SMMC LTC enrollee incurs a charge for a medically necessary service that is not covered by a third party payer, Medicare, or is not covered under the Medicaid program, the SMMC Managed Medical Assistance (MMA) program, or the SMMC LTC program. 23
What is an uncovered medical expense deduction (UMED)? When DCF approves an uncovered medical expense as medically necessary, DCF reduces the monthly amount of the enrollee s patient responsibility by the amount of the uncovered medical expense, for one or more months. This type of a reduction in the amount of patient responsibility is referred to as an uncovered medical expense deduction, or simply a UMED. 24
What qualifies as UMED? Any premium, deductible, or coinsurance charge for health insurance coverage; or other incurred medical expenses approved by DCF. Examples of other incurred medical expenses that DCF may approve as medical necessary might include dental services, hearing supplies and services, or vision services and supplies. For more information on UMEDs refer to the DCF SSI-Related Fact Sheets accessible on this DCF Web site http://www.myflfamilies.com/service-programs/access-florida-foodmedical-assistance-cash/medicaid. 25
How are UMED requests submitted to DCF? Enrollees must notify DCF of what medical expenses (paid or unpaid) they have to pay within ten days after receiving a bill/receipt. Enrollees may submit proof of medical expenses and other documentation to DCF by: uploading files to the enrollee s MyACCESS Account; faxing 1-866-886-4342; or mailing the ACCESS Central Mail Center PO Box 1770 Ocala, FL 34478-1770 26
Does DCF notify enrollees about changes in patient responsibility? Yes. DCF mails a Notice of Case Action (NOCA) to the enrollee when there is a change in the monthly amount of patient responsibility. If DCF has a record of the enrollee s representative or SMMC LTC case manager, DCF will also mail a copy of the NOCA to those entities. 27
Can information about the enrollee s patient responsibility be viewed online? Yes. Health plans and providers may view enrollee patient responsibility information via the DCF Provider View option in the Florida Medicaid Secure Provider Web Portal. Access a DCF Provider View training presentation on this DCF Web site http://myflfamilies.com/general-information/dcf-training. Contact DCF if you have questions about the information displayed in DCF Provider View by calling 1-866-762-2237. Contact the Medicaid fiscal agent if you have questions about accessing DCF Provider View on the Medicaid Web Portal by calling 1-800-289-7799. 28
Florida Medicaid Secure Provider Web Portal 29
ACCESS Florida: Search DCF Provider View 30
My Benefits: Select Details 31
Medical Assistance: Select History 32
Medicaid History: Patient Responsibility *data up to the last 12 months from date of inquiry 33
How does the SMMC LTC plan collect patient responsibility from an enrollee that resides in an ALF? Each SMMC LTC plan must determine how patient responsibility will be collected from their enrollees. SMMC contract, Attachment II, Exhibit II-B Section X.D.1.a., Effective 8/15/16. SMMC Model Contract accessible at this Web site: http://ahca.myflorida.com/medicaid/statewide_mc/plans.shtml. 34
Can the SMMC LTC plan delegate collection of patient responsibility to the enrollee s ALF? Yes. The SMMC LTC plan may delegate collection of patient responsibility to the enrollee s ALF. SMMC contract, Attachment II, Exhibit II-B Section X.D.1.b., Effective 8/15/16. SMMC Model Contract accessible at this Web site: http://ahca.myflorida.com/medicaid/statewide_mc/plans.shtml. 35
How will the enrollee know if the SMMC LTC plan delegated collection of patient responsibility to the ALF? The SMMC LTC plan s enrollee handbook must contain information about the collection of patient responsibility in a residential facility, such as an ALF. SMMC contract, Attachment II, Exhibit II-B, Section IV.A.2.g., Effective 8/15/16 SMMC Model Contract accessible at this Web site: http://ahca.myflorida.com/medicaid/statewide_mc/plans.shtml. 36
How does the ALF know how the SMMC LTC plans will collect patient responsibility from their enrollees? The SMMC LTC plan s provider handbook and the provider contract must contain information about the collection of patient responsibility. SMMC contract, Attachment II, Exhibit II-B Section VI.C.2.a.(2), Effective 8/15/16. SMMC contract, Attachment II, Exhibit II-B Section VI.D.2.a.(3), Effective 8/15/16. SMMC Model Contract accessible at this Web site: http://ahca.myflorida.com/medicaid/statewide_mc/plans.shtml. 37
How does the SMMC LTC plan collect patient responsibility if the ALF collects patient responsibility from the enrollee? The LTC plan contracts with an ALF to provide an enrollee with home and community-based services (HCBS) for a monthly rate. The LTC plan and the ALF agree that payment for those HCBS will be that monthly rate less the amount of the enrollee s monthly patient responsibility. See the next slide for an example. 38
This is an example of a LTC plan s monthly payment to an ALF for the provision of HCBS to a LTC enrollee, being reduced by the amount of that LTC enrollee s monthly patient responsibility. $1,200 LTC Plan s Monthly Rate for ALF HCBS -$ 52 Enrollee s Monthly Patient Responsibility $1,148 LTC Plan s Payment to the ALF for HCBS 39
If the ALF collects patient responsibility, will the enrollee pay the ALF both room and board, and patient responsibility? Yes. If the ALF collects patient responsibility, the enrollee will pay the ALF both the monthly room and board charges and the monthly patient responsibility. See the next slide for an example. 40
This is an example of example of a LTC enrollee s monthly payment to an ALF. $1,500 Monthly ALF Room and Board Rate + $ 52 Enrollee s Monthly Patient Responsibility $1,552 Enrollee s Payment to the ALF 41
When a SMMC LTC enrollee resides in an ALF during calendar year 2016, should the amount of the personal needs allowance on the DCF Notice of Case Action be an amount greater than $198.00 during any month the enrollee s income was greater than $198.00? Yes. The total amount of the personal needs allowance on the DCF Notice of Case Action should include the cost of the monthly ALF basic room & board charge, not simply the $198.00 personal needs allowance for any enrollee in the SMMC LTC program that resides in an ALF during calendar year 2016. For more information refer to the DCF SSI-Related Fact Sheets accessible on this DCF Web site http://www.myflfamilies.com/service-programs/access-florida-foodmedical-assistance-cash/medicaid. 42
What can a health plan do to assist a SMMC LTC enrollee that resides in an ALF if the amount of the personal needs allowance on the DCF Notice of Case Action is only $198.00 during any month in calendar year 2016 when the enrollee s income was greater than $198.00? The health plan may assist the enrollee by obtaining the appropriate letter from the enrollee s assisted living facility (ALF) and submit this letter to DCF as an attachment to a completed DCF form CF-ES 2515 Certification of Enrollment Status Home and Community Based Services (HCBS). DCF will recalculate the enrollee s patient responsibility, and the new amount of the personal needs allowance will reflect payment of the ALF s basic monthly room and board rate. DCF forms are accessible on this DCF Web site: http://www.dcf.state.fl.us/dcfforms/search/dcfformsearch.aspx. 43
What is the DCF Optional State Supplementation (OSS) Program? This is not a Medicaid program. The OSS Program is operated by the DCF. The OSS Program provides monthly cash payments to indigent elderly or disabled individuals who live in special non-institutional, residential living facilities, including assisted living facilities, adult family care homes and mental health residential treatment facilities. For more information on the OSS Program refer to the DCF SSI-Related Fact Sheets accessible on this DCF Web site http://www.myflfamilies.com/service-programs/access-floridafood-medical-assistance-cash/medicaid. 44
Have questions about the information in this presentation? Health Plans: contact your Agency contract manager. Enrollees: ALFs: contact your health plan. contact your enrollee s health plan. 45
Have questions about an enrollee s patient responsibility? When an enrollee s health plan or Medicaid provider is unable to obtain needed information through the DCF Provider View, they may contact the DCF Customer Call Center at 1-866-762-2237. If a call agent is unable to resolve their inquiry, the issue will be referred to the regional office. The regional office has 24 hours to respond once alerted that action is needed on a case. This information can be found on the DCF: Adult Related Medicaid Provider Communication Guide, that is accessible via this link: http://www.dcf.state.fl.us/programs/access/docs/ssi- RelatedProviderCommunicationFlyer.pdf. 46
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