Making the Most of Your Florida Medicaid and ibudget Services Information for Individuals, Families, and Service Providers Created by the Florida Developmental Disabilities Council, Inc. Table of Contents Page Accessing Home Health Care, Nursing, and Personal Supports for Individuals 2 who Receive Florida Medicaid and ibudget Services How to Get a Customized Wheelchair through Florida Medicaid 8 How to Access Transportation to Work When You Receive ibudget Services 14 Disclaimer: The information contained in this guide is for the use of individuals with intellectual and developmental disabilities who receive services through Florida Medicaid and the ibudget Waiver. Families, Providers, and Support Coordinators may also benefit from this information. No endorsement by the Agency for Healthcare Administration or the Agency for Persons with Disabilities is provided or implied. Every attempt has been made to ensure the accuracy and reliability of the information provided in this guide. The Florida Developmental Disabilities Council, Inc. does not accept any responsibility or liability for the accuracy, content, completeness, legality, or reliability of the information contained in this guide. Sponsored by United States Department of Health and Human Services, Administration on Intellectual and Developmental Disabilities and the Florida Developmental Disabilities Council, Inc. 1
Accessing Home Health Care, Nursing, and Personal Supports for Individuals who Receive Florida Medicaid and ibudget Services 2
Accessing Home Health Care, Nursing, and Personal Supports for Individuals who receive Florida Medicaid State Plan and ibudget Services. Do you need help taking care of yourself or taking care of a family member? If you have Florida Medicaid or the ibudget Waiver you might be able to get help. Often people don t know what to ask for or don t know what services they can get. This guide is created to help you understand what assistance you might be able to get and to help you decide what to request. Services available for Individuals under 21 years of age Home health agencies provide nursing services, Home Health aides, Private Duty Nursing, and Personal Care Services for children under 21. If the Home Health agency is approved by Florida Medicaid as a Florida Medicaid provider, these services may be paid for by Florida Medicaid and you do not have to be on a Medicaid waiver to get these services. People who get Florida Medicaid sometimes get their Medicaid services directly through Medicaid. This situation is called Medicaid fee-for-service or direct Medicaid. People on direct Medicaid go to a Medicaid provider and the Medicaid provider bills for the service if it is medically necessary. The provider may need to get approval from a company that works for Florida Medicaid called eqhealth to be sure that the services are medically necessary before they can provide the services. This means you must really need the medical services. Other people who receive Florida Medicaid get their Medicaid care through managed care plans. If you get your services through a Medicaid managed care plan, your Home Health agency may need to get approval from the managed care company before they can provide some of these services. Home Health Visits Florida Medicaid provides Home Health services in a person s home. Home Health visits are provided by Home Health Aides, Registered Nurses (RN), or Licensed Practical Nurses (LPN). Home Health Aide Home Health Aide services are provided through the Home Health agency by persons who have had special training but are not licensed nurses. They are allowed to do activities that do not require a licensed nurse to do. Some examples of the types of help that are available through Home Health aides are listed below: Helping change a colostomy bag. Helping you to transfer from a wheelchair to a bed, shower, or other surface. Helping to look at a bandage for a cut or sore. Helping you to practice moving and doing special exercises that a Registered Nurse has told you must be done. Helping you to prepare and measure a special diet. Help with teeth brushing and keeping your mouth clean if you can t do that for yourself. Helping you take a bath and being sure that your skin is kept in good condition. 3
Helping you take medication if you know what medications you need to take but just need help with taking them. Home Health aides can come to your home or other places in the community up to four times a day. If you need more help than that you may need Nursing Services or Personal Care Assistance. Personal Care Services are discussed more in a section below. Nursing Services The type of nursing assistance provided is based on the needs of the person receiving services. Registered Nurses have a higher level of training than Licensed Practical Nurses do, so there are some duties that only Registered Nurses can do. You won t have to figure this out; your doctor and the Home Health agency will help you. Nursing care is help that the law says must be done by trained nurses with a nursing license. Sometimes people do these things for themselves, but when they can t they need a nurse to do them. Below are examples of what nurses can help you or your family member with: Injections for medications if you cannot do them yourself. Help with putting in catheters. Caring for a colostomy. Caring for a deep sore called a decubitus ulcer or other sores and making sure that they stay clean and don t get infected. Helping take care of a tracheotomy or ventilator. Helping take care of feedings through a gastrostomy tube if you or your caregiver can t do it. The nurses that provide this service can come one to four times a day. If you need more help than that you may need Private Duty Nursing which is discussed more below. Private Duty Nursing Private Duty Nursing is a skilled nursing service that provides help from a licensed nurse for several hours a day at your home or a place in the community. The services are provided to perform skilled nursing interventions or monitor the effects of treatment. To be eligible, you or your family member must have many severe medical problems. Florida Medicaid calls this condition medically complex ; this means that a person has a continual disease or medical condition that keeps them from doing most things for themselves or makes them need medical care most of the time. The Private Duty Nurse can either teach a family member to help or provide services directly. If the person receiving nursing services has a family member that is a licensed nurse in Florida and he/she wants to be the Private Duty Nurse for a family member, that person can get a job with a Home Health agency and provide the service. Or if the Home Health agency does not have a nurse available to help you, a licensed nurse who does not work for a Home Health agency can become a Florida Medicaid provider and provide the service and get paid by Medicaid. Some children under 21 who have medically complex conditions go to a program during the day called Pediatric Prescribed Extended Care or PPEC. Even if a child is getting services during the day at a PPEC, you may be able to get Private Duty Nursing during the evening if you need it. 4
Some children live in Medical Foster Care. These children need a lot of medical care. Sometimes this care is more than the foster parent can do. Private Duty Nursing may be available to help the foster parents take care of the child when necessary. Private Duty Nursing may be provided at the child s school. Some things to consider are: The doctor thinks that it is okay for the child to go to school. The school does not have the level of nursing care available to take care of the child. Receiving Private Duty Nursing will allow the child to go to school. Sometimes you might not need a licensed person to help you. You may just need someone to come to your home or community to help you do things that you or your family member can t do for yourself. You may need a Home Health Aide or Personal Care Services instead. Personal Care Services If you or your family member needs more help than you can get through a Home Health Aide but you don t need Private Duty Nursing, you may need Personal Care Services. Personal Care Services provide similar types of services that the Home Health Aide provides that do not require a nurse to do them. A Personal Care Attendant can help with eating, bathing, dressing, going to the bathroom, transferring to and from a wheelchair, and helping change a catheter or colostomy bag. A Personal Care Attendant can also help with bathing, light housework, laundry, cooking, transportation, grocery shopping, paying bills, setting up medical appointments, and managing medication and money. Personal Care Services can be provided in the home and other places in the community. They can be provided at school when they are necessary for the child to go to school. The personal care assistance can be provided through a Home Health agency, an independent personal care provider, or an independent personal care provider group. The biggest difference between Home Health Visits and Personal Care Services is the amount of help that you get. Home Health Aides can only come to your home up to four times a day. Personal Care Services can be provided for several hours a day and continually. For example, if you need help for several hours in the morning to get ready for work or school and then several hours in the evening to prepare for bed, a Personal Care Attendant can provide this kind of help. How Can I Get This Help? The services that are described in the section above require proof of Medical Necessity and Prior Authorization. Medical Necessity means that you need to show that the services are required for you or your family member to be healthy and that there are no other ways to provide the needed help. Prior Authorization means that Florida Medicaid says that the service is medically necessary before it is provided. If you or your family member are enrolled in a managed care company, the prior authorization must go through the managed care company. If you or your family member are not enrolled in a managed care company, then the prior authorization must go through a company called eqhealth. 5
How to get Prior Authorization In order to get a prior authorization the following must be obtained: Your doctor must order the service. The service must be included on the doctor s approved plan for care. Florida Medicaid must say that it is medically necessary and they do this by giving prior authorization. Once you or your family member have been prescribed the service, you must find an approved Home Health agency or other provider such as an independent provider for Private Duty Nursing or Personal Care Services. If you are not on a managed care plan, the Home Health agency will send the prescription and documents to eqhealth for prior authorization. For assistance, contact the Florida Medicaid Help Line at 1-877-254-1055. If you are on a managed care plan, the provider will send the prescription to the managed care company for approval. Services available for individuals over 21 who receive ibudget services If you are 21 or older, you still can get most of your nursing services and Home Health Hide services through the Florida Medicaid program. If you need Private Duty Nursing or Personal Supports like Personal Care Services, you may now get these services through the ibudget Waiver. These services will have to be approved by the Agency for Persons with Disabilities (APD) and be on your cost plan. The services that are on the ibudget Waiver are: Skilled Nursing Skilled Nursing is the name for the ibudget Waiver service that is just like Medicaid Home Health Visits Nursing Services. Licensed Practical Nurses or Registered Nurses can come to your home or other places in the community to provide nursing services if you need them. For people who receive ibudget services, almost all nursing services are paid for by Florida Medicaid either directly through Medicaid as fee-for-service or through a managed care plan. This helps you or your family member because the service does not go on your ibudget cost plan. If you or your family member are having problems getting nursing services from Medicaid, you can sometimes get nursing services from the ibudget Waiver. Your Support Coordinator can help you with this if necessary. You or your family member will have to get special approval for this. It is called getting an Exception Letter. Your Support Coordinator will have to help you get the letter. Private Duty Nursing Private Duty Nursing is available through Florida Medicaid for individuals under 21 years old. When you or your family member turn 21, Florida Medicaid will no longer pay for this service. If you or your family member still need this help, you will have to get it through the ibudget Waiver. Your doctor, ARNP, or Physician's Assistant must prescribe this service. Private Duty Nursing through the ibudget Waiver is just like the Private Duty Nursing under Florida Medicaid. A licensed nurse can come to your home or where you are in the community and provide the type of nursing care that you need. The difference between Private Duty 6
Nursing, Health Home Visit Nursing, and ibudget Waiver Skilled Nursing services is the amount of time that you or your family member need the nurse. If a nurse can come into your home four times a day and provide what you need, then you probably don t need a Private Duty Nurse. But if you or your family member need a nurse most of the time then you probably need a Private Duty Nurse. Also remember that if you need help with taking care of yourself or your family member, you may not need a nurse if the help you need does not require a licensed person to do it. You may be able to have Personal Supports to help you. Personal Supports If you or your family member were getting Personal Care Assistance through Florida Medicaid and you are now 21 or turning 21, you will have to change your services to Personal Supports services through the ibudget Waiver. Your assistant will need to be paid by the ibudget Waiver after you turn 21 and must be an ibudget Waiver provider. Your Support Coordinator can help them figure out how to become an ibudget Waiver provider. The Personal Supports service under the ibudget Waiver is very similar to the Personal Care services under Florida Medicaid. The Personal Support worker can help you or your family member with eating, bathing, dressing, personal hygiene, and meal preparation. They also can help you or your family member with cleaning your home, washing clothes, and going into the community to shop or do other activities. How do I get these services approved? You may be able to get Private Duty Nursing and Personal Supports approved by working with your Support Coordinator to have them included on your Support Plan and cost plan. Your Support Coordinator will help you decide which type of services you need. You can also combine services. For example, if you need nursing services only once a day, you can get them through Medicaid and can also get Personal Supports through the ibudget Waiver. For Private Duty Nursing, you must have a prescription from a doctor, Advanced Registered Nurse Practitioner (ARNP), or Physician s Assistant and have a nursing assessment that says that you need the service. Disclaimer: The information contained in this guide is for the use of individuals with intellectual and developmental disabilities who receive services through Florida Medicaid and the ibudget Waiver. Families, Providers, and Support Coordinators may also benefit from this information. No endorsement by the Agency for Healthcare Administration or the Agency for Persons with Disabilities is provided or implied. Every attempt has been made to ensure the accuracy and reliability of the information provided in this guide. The Florida Developmental Disabilities Council, Inc. does not accept any responsibility or liability for the accuracy, content, completeness, legality, or reliability of the information contained in this guide. Sponsored by United States Department of Health and Human Services, Administration on Intellectual and Developmental Disabilities and the Florida Developmental Disabilities Council, Inc. 7
How to Get a Customized Wheelchair through Florida Medicaid Created by the Florida Developmental Disabilities Council, Inc. 8
How to Get a Customized Wheelchair through Florida Medicaid What is a customized wheelchair? A customized wheelchair cannot be directly purchased from the manufacturer. A customized wheelchair is a wheelchair that has been made just for you so that it is comfortable for you, helps you stay healthy, and allows you to do the things that you need to do. It can be either manual or powered. Manual means that you or someone else has to move the wheelchair by rolling it, by turning the wheelchair wheels, or by pushing it. A power wheelchair uses batteries to power it and it moves by the person pushing a lever. Where do I get a customized wheelchair? A customized wheelchair is made by a Durable Medical Equipment (DME) company. DME companies will be able to help you get your customized wheelchair through Florida Medicaid or Medicare, depending on what program you receive services from. Will Florida Medicaid pay for a customized wheelchair? Yes, Florida Medicaid will pay for a customized wheelchair. Even if you are on the ibudget Waiver you will need to get your wheelchair through the regular Florida Medicaid program. Regular Medicaid means the Florida Medicaid State Plan services that all Florida Medicaid recipients get even if they are on a Waiver like the ibudget Waiver. This means that the cost of your wheelchair will not be counted in your ibudget cost plan. Even though the ibudget Waiver is not paying for your wheelchair, your Support Coordinator can still help you with the steps for getting your wheelchair. Florida Medicaid has rules about when they will pay for a customized wheelchair. These rules are listed below: You have to plan to use the wheelchair in your own home and community. You also can be living in a group home or an assisted living facility. If you are under 18 and live in a nursing home, you can get a wheelchair through Florida Medicaid. If you are 18 or older and live in a nursing home or live in an intermediate care facility, you will have to ask the home or facility to help you get a wheelchair. Florida Medicaid will only pay for a new customized wheelchair once every five years and if you need it. If your wheelchair is still meeting your needs or can be fixed, Florida Medicaid will not provide a new wheelchair. Florida Medicaid will not pay for a wheelchair or custom upgrade unless you or your family member must have the wheelchair to do daily living activities such as bathing, eating, using the bathroom, dressing, transferring in and out of bed or a chair, or moving about within your home. 9
How to get started Medical Necessity and Prior Authorization You have to show Florida Medicaid that you need a customized wheelchair. You must show that you are not mobile without the customized wheelchair. Florida Medicaid calls this having Medical Necessity. It simply means that you must have a customized wheelchair to do the things that are necessary for your daily life, to stay healthy, to take care of yourself, and help others to help you. To be sure that you need a customized wheelchair, Florida Medicaid will prior authorize (approve) your wheelchair. This means that you have to go through several steps to get the paperwork necessary for prior approval. Step 1 - You must get a prescription from a doctor A doctor must tell Florida Medicaid that you need a special or customized wheelchair. You will have to make an appointment with a doctor and the doctor can write a prescription for a wheelchair after they examine you. A Physician s Assistant (PA) or Advanced Registered Nurse Practitioner (ARNP), can also write the prescription. The prescription is a piece of paper that you will use to show you need a customized wheelchair. For wheelchairs, this prescription is called a Certificate of Medical Necessity. This form must be signed and dated by the physician, PA, or ARNP. You also will need a prescription for a wheelchair evaluation. More information about wheelchair evaluations is given in Step 3. What to do with my doctor s office: What I Must Do What the Doctor Must Do Make an appointment with a doctor. Examine you Tell them that I need their help to get a Tell you whether or not you need a customized wheelchair. customized wheelchair. Get the needed paperwork. Write a prescription on a form called a Certificate of Medical Necessity and sign and date it. Write a prescription for a wheelchair evaluation. Step 2 - You must talk to a Durable Medical Equipment (DME) company Next, you must talk to a DME company. Your doctor or Support Coordinator can tell you where there is a DME company in your area. You must go to the company and talk to them about what needs to happen next for you to get a customized wheelchair. You will have to have a customized wheelchair evaluation completed by a Physical or Occulational Therapist or a Physiatrist (a special doctor with additional training to help people with serious injuries or disabilities). You may already go to one of these professionals; or the DME company may work with one of these types of professionals and want you to go to them. If that is the case, the company staff person will give you the contact information to make an appointment. Next, you must make an appointment to have a customized wheelchair evaluation. 10
Step 3 - You must get your wheelchair evaluation with a physical or occupational therapist or a physiatrist The therapist or physiatrist will examine you and complete the paperwork that is required for you to get prior approval for your wheelchair. You must give them the prescription that you got from your doctor for the wheelchair evaluation. The therapist or physiatrist will do the following things: Describe your physical condition and why you need a customized wheelchair. If you are getting a power wheelchair, the evaluation must say that you are able to use the chair safely. Describe all the extra things that your wheelchair will need for you to be comfortable and healthy and allow you to do all the things you need to do. Explain why each of the extra things on the wheelchair are required for you, and what could happen to your health if you don t get these special items. Describe where you are going to use your wheelchair. For example, you may use your wheelchair in your home, going to the store, for activities in the community, or going to work. Take measurements from your home of your hallways and doors to be sure that you will be able to use the customized wheelchair at your home. If you are getting a powered wheelchair, even more information must be included. The therapist or physiatrist must tell Florida Medicaid why you need a powered wheelchair and that you will be able to use it. They must include the following information in the paperwork: That you are not able to use your arms well enough to move a regular wheelchair. That you will be able to operate your power chair safely. That you will be able to use your wheelchair where you live and spend your time. What type of daily activities you do and that you are able to move in and out of your wheelchair. The therapist or physiatrist must fill out forms and send them to Florida Medicaid: They will complete a form called the Custom Wheelchair Evaluation, AHCA Med Serv Form 015. If they don t complete this form, the therapist or the physiatrist must describe the exact information that is required in this form. This information and your Certificate of Medical Necessity must be turned in to Florida Medicaid. The DME company will turn in all their information to Florida Medicaid. 11
What Must I Do Make an appointment with a therapist or physiatrist for a wheelchair evaluation. Take my prescription or Certificate of Medical Necessity from my doctor to the appointment. Be ready to describe how I need to use my wheelchair. Be willing for measurements to be taken at my home. What the Therapist or Physiatrist Must Do Evaluate you to decide what kind of extra things you need on your wheelchair. Explain to Florida Medicaid why you need these extra things or why you need a power wheelchair. Complete paperwork explaining why you need a customized wheelchair to stay healthy and do the things that you want to do. Step 4 - Return to the DME company The final step is to return all the paperwork to the DME company. You must bring the Certificate of Medical Necessity and wheelchair prescription from your physician and the completed Custom Wheelchair Evaluation form, AHCA Med Serv Form 015. If the therapist or physiatrist did not complete this form, they must have completed a report that describes the exact information that is required in this form. You need to take that report to the DME company. The DME company will submit all the paperwork for approval. The DME company must have an account with a company called eqhealth. This company has a contract with Florida Medicaid and is responsible for approving durable medical equipment for Florida Medicaid. The request must be submitted electronically through eqhealth system (eqsuite) at http://fl.eqhs.org eqhealth Solutions Customer Service can be reached toll free at: 855-444-3747, 8:00 a.m. 5:00 p.m. Eastern Time. The wheelchair evaluation only lasts for six months, so you need to be sure that they send the information in to Florida Medicaid right away. What Must I Do What the DME Company Must Do Return to the DME company. Submit the information to eqhealth immediately. Take my prescription or Certificate of Follow-up with eqhealth and get Medical Necessity from my doctor to approval. the DME company. Take the form Custom Wheelchair Evaluation, AHCA Med Serv Form 015 or report from the therapist or physiatrist to the DME company. Follow-up to be sure that the company submits the necessary information to eqhealth immediately. 12
Step 5 Florida Medicaid approves your wheelchair If Florida Medicaid approves your wheelchair, the DME company will order and build your wheelchair. The DME company will tell you about how long it will take to complete the customized wheelchair. Your new wheelchair must come with a one year warranty. Step 6 - You must be trained in how to use your customized wheelchair Your therapist or physiatrist must be there when you get your new wheelchair to be sure that it fits correctly and that you are going to be able to use it safely. Your DME company will arrange with your therapist or physiatrist for you to be trained in the use of your customized wheelchair. The DME company is required to do the following things: Provide the customized wheelchair directly to you or your caregiver at the provider s location, your home or school, or appropriate clinical location; Honor the manufacturer warranties in a timely manner; Maintain and repair equipment, per manufacturer recommendations; and Provide individual maintenance and maintain service records on your customized wheelchair. If your request is not approved If Florida Medicaid does not approve your wheelchair, they should tell you why they did not approve your request. If you do not think that they are correct, you can file a complaint with Florida Medicaid. If you are with a managed care company, you can use Florida Medicaid s special complaint line. Your DME company, therapist, or Support Coordinator can probably help you. More information is available at https://apps.ahca.myflorida.com/smmc_cirts/ If you are not on a Florida Medicaid managed care plan, you can request a reconsideration. A Reconsideration of Medical Necessity Denial form will have to be sent to eqhealth through eqsuite. You can find the reconsideration request form on http://fl.eqhs.org under the Therapy/DME tab, Forms and Downloads folder. Disclaimer: The information contained in this guide is for the use of individuals with intellectual and developmental disabilities who receive services through Florida Medicaid and the ibudget Waiver. Families, Providers, and Support Coordinators may also benefit from this information. No endorsement by the Agency for Healthcare Administration or the Agency for Persons with Disabilities is provided or implied. Every attempt has been made to ensure the accuracy and reliability of the information provided in this guide. The Florida Developmental Disabilities Council, Inc. does not accept any responsibility or liability for the accuracy, content, completeness, legality, or reliability of the information contained in this guide. Sponsored by United States Department of Health and Human Services, Administration on Intellectual and Developmental Disabilities and the Florida Developmental Disabilities Council, Inc. 13
How to Access Transportation to Work When You Receive ibudget Services Disclaimer: The information contained in this guide is for the use of individuals with intellectual and developmental disabilities who receive services through Florida Medicaid and the ibudget Waiver. Families, Providers, and Support Coordinators may also benefit from this information. No endorsement by the Agency for Healthcare Administration or the Agency for Persons with Disabilities is provided or implied. Every attempt has been made to ensure the accuracy and reliability of the information provided in this guide. The Florida Developmental Disabilities Council, Inc. does not accept any responsibility or liability for the accuracy, content, completeness, legality, or reliability of the information contained in this guide. Sponsored by United States Department of Health and Human Services, Administration on Intellectual and Developmental Disabilities and the Florida Developmental Disabilities Council, Inc. 14