FAHA H&S: AHCA FAQs

The below Frequently Asked Questions (FAQs) were part of a larger FAQs located on the AHCA website [PDF]. These questions were selected to focus on many of the questions that have been received to date.

General Medicaid and Statewide Medicaid Managed Care (SMMC) Questions

Question: How will current Doctors who accept Medicaid gold fee for service be informed that most of their patients will have to be in managed Medicaid even dual eligibles?
Answer: Physician Services is not a covered service under the long-term care program. Medicaid recipients who are enrolled in the long-term care (LONG-TERM CARE (LTC)) program will continue to receive their physician services through Medicare or the Medicaid medical assistance program.

Question: Are there any co-pays associated with selecting a plan or for some specific services (currently there are co-pays for non-emergency transportation, for example)?
Answer: LONG-TERM CARE (LTC) plan enrollees will have no co-pays for long-term care services. However, there may be patient responsibility for nursing facility or home and community- based services. Patient responsibility will continue to be calculated by the Department of Children and Families.

Question: Are there any changes to the way co-insurance would work?
Answer: The LONG-TERM CARE (LTC) plans are responsible for any LONG-TERM CARE (LTC) co-insurance due for their plan members.

Question: Is ACS going away? How does that change checking for eligibility?
Answer: The Florida Medicaid Managed Information System (FMMIS) and the Medicaid Eligibility Verification System (MEVS) will continue to be available to verify Medicaid eligibility.

Home Like Environment

Question: Does the new requirement require the residents to have a private room if they request one? Who is responsible to pay for this private room for Medicaid eligible individuals?
Answer: To satisfy the home-like environment and community integration requirements established by the state, assisted living facilities and adult family care homes must ensure that waiver enrollees have the choice of private or semi-private rooms. This means that waiver enrollees must be presented the option of both a private and semi-private room. It may be that the enrollee is unable to afford a private room, although he or she wants one. Neither the assisted living facility/adult family care home provider nor the managed care plan is required to pay for the enrollee’s private room if he or she chooses one and cannot afford it. The assisted living facility/adult family care home provider and the managed care plan are responsible for ensuring and documenting in case records that the enrollee has been offered the choice of both a private and semi-private room.

LONG-TERM CARE (LTC) Recipient Eligiblity

Question: Are Hospice recipients required to select a Long-Term Care (LTC) health plan?
Answer: Hospice recipients must select a Long-Term Care (LTC) health plan if they are Medicaid
recipients age 18 or older residing in a nursing facility or receiving services through one of the identified home and community-based waiver programs that will be transitioning into the Long-Term Care Managed Care Program.

Question: Will the Institutional Care Program (ICP) Medicaid application process remain the same?
Answer: Yes, financial eligibility determination for ICP Medicaid will continue to be the responsibility of the Department of Children and Families. Comprehensive Assessment and Review for Long-Term Care Services (CARES) staff will continue to be responsible for determining medical eligibility for Medicaid long-term care services.

Question: If a resident is already ICP Medicaid approved, then decided to go home. Will this affect the resident's community Medicaid eligibility? Where do we fax the discharged change form to?
Answer: When a Medicaid recipient in a nursing facility is preparing to return home, the long-term care plan’s case manager should work closely with the patient, the patient’s designated representative, and the nursing facility to make sure that all community supports and services are in place prior to discharge. It will still be the responsibility of the nursing facility to notify the Department of Children and Families of the patient’s discharge via the Client Discharge/Change Notice form.

Question: Once individuals are released from the wait list, who will be responsible for completing the initial assessment for people under the age 60 to determine the care plan?
Answer: DOEA's CARES staff is responsible for completing the initial assessment for individuals 18 and older, once released from the waiting list, in order to determine level of care.

Question: Once someone is in the Long-term Care Managed Care program and enrolled in a Long-Term Care (LTC) health plan, is the Long-Term Care (LTC) health plan the sole entity who determines the level of care needed?
Answer: No, the Long-Term Care (LTC) health plan does not determine Level of Care. The Long-Term Care (LTC) health plan completes the annual 701 B reassessment and submits the assessment to CARES. DOEA CARES staff determine the Level of Care independently of the health plans. The LONG-TERM CARE (LTC) health plan is, however, responsible for working with their enrollees to create a comprehensive plan of care that lists all needed services. If an enrollee is denied a service or is authorized for fewer services than he believes he needs, he can appeal through the plan’s grievance process and/or through the Medicaid Fair Hearing process.

Question: Will the level of care criteria change under the Long-term Care Managed Care program? If so, then how?
Answer: Medicaid long-term care eligibility requirements for nursing facility care and home and community-based waiver services, including the level of care process, will not change with implementation of the Long-Term Care Managed Care Program.

Question: What will happen to pediatric patients who are currently residing in a nursing facility? Will they be required to select a LONG-TERM CARE (LTC) health plan?
Answer: Medicaid recipients must be age 18 or older in order to be eligible to participate in the Long-Term Care Managed Care Program. Pediatric patients under the age of 18 will not be required to select a LONG-TERM CARE (LTC) health plan.

Plan Payment to Providers

Question: Do physicians need to enroll in Medicaid Managed Care?
Answer: Physician Services are not covered service under the managed long-term care program. Medicaid recipients who are enrolled in the managed long-term care program will continue to receive their physician services through Medicare or the Medicaid medical assistance program. However, Medicaid is moving to managed care for physician services and other medical services in 2014, so physicians who wish to continue serving Medicaid patients should stay informed about the upcoming Managed Medicaid Assistance program.

Question: How will patient responsibility be handled under the Long-term Care Managed Care program? Will it be the same regardless of whether the LONG-TERM CARE (LTC) health plan is capitated or fee-for-service?
Answer: All capitated and fee-for-service LONG-TERM CARE (LTC) health plans will be responsible for collecting its enrollee's patient responsibility. The LONG-TERM CARE (LTC) health plan may transfer the responsibility for collecting its enrollee's patient responsibility to the residential facilities and compensate the facilities net of the patient responsibility amount. If the plan transfers collection of patient responsibility to the provider, the provider contract must specify complete details of both parties' obligations for collection of patient responsibility. The plan must either collect patient responsibility from all of its providers or transfer collection to all providers.

Question: On an MDS standpoint. Would we continue with the OBRA schedule or follow the PPS schedule for reimbursement once the Long-term Care Managed Care program is implemented on our region?
Answer: The Long-term Care Managed Care program does not impact the administration of MDS in nursing facilities.

Recipient Enrollment and Transition

Question: Will dual eligibles (those with both Medicare and Medicaid coverage) be required to enroll in a health plan under the Statewide Medicaid Managed Care program?
Answer: Dual eligibles will be required to select a Managed Medical Assistance plan for coverage of their Medicaid acute care benefits, which can include coverage of co- payments or premiums or coverage of additional medical services not covered under the Medicare program. Dual eligibles who qualify for enrollment in a Longterm Care Managed Care plan are required to enroll in a Long-term Care plan in order to receive Medicaid covered long-term care services However, Medicare recipients will NOT be required to make a change to their Medicare Advantage plan choice.

Question: Will dual eligibles be handled under the statewide expansion by a special program, or will they be directed to specialty plans such as United Evercare, or will they be absorbed with the rest of the Medicaid population?
Answer: There is not a separate program for dual eligibles. Duals eligible for the Long-term Care (LONG-TERM CARE (LTC)) program must choose a LONG-TERM CARE (LTC) plan. Those not eligible for LONG-TERM CARE (LTC), will choose a Managed Medical Assistance (MMA) plan when one becomes available in their area. In both the LONG-TERM CARE (LTC) and MMA programs, if a dual eligible does not make a choice of plan, he or she will be assigned to a plan.

Question: Will an Aged and Disabled Adult Waiver client currently in a Medicare Advantage plan be required to change their Medicare plan to one of the assigned providers in their county?
Answer: No, the Long-term Care Managed Care Program does not impact Medicare in any way. Individuals enrolled in a Medicare Advantage plan will stay in that plan. Medicaid LONG-TERM CARE (LTC) health plans will be responsible for coordinating services between Medicare and Medicaid for their members.

Question: What happens, if a major insurer (with an advantage plan), currently has Medicaid LONG-TERM CARE (LTC) patient in Waiver or Diversion, and they do not win in the procurement process. Do they get to keep their patients? If so, for how long?
Answer: Current providers that do not win a contract through the procurement or who do not choose to participate through non-bidding will keep their enrollees until the program goes live in their region.

Question: Will plans be able to force a recipient to move out of their nursing home?
Answer: No, a recipient residing in a nursing facility can always choose to remain in that facility, if this is the least restrictive setting that can provide the appropriate level of care for that individual

Question: What effect will this have on Qualified Medicare Beneficiary (QMB) benefits for Medicare co-insurance, if any? If a resident that is in a skilled nursing facility and needs to apply for ICP to cover the Medicare A co-insurance, how will that work? Will they still need to choose a Medicaid managed care plan, or will they be approved for the straight ICP Medicaid for that situation?
Answer: If nursing home residents with QUALIFIED MEDICARE BENEFICIARY (QMB) coverage who are not already enrolled in a managed long-term care plan are admitted to a skilled nursing facility for a brief stay, the residents may not need to apply for ICP benefits, and therefore would not enroll in managed care. If a resident needs to remain in the nursing facility after the skilled Medicare benefits have ended, then once the ICP application is filed with DCF, the resident would receive choice counseling materials instructing the resident to select a managed long-term care plan. Once the ICP application is approved and Medicaid is the primary payer, the resident would be enrolled with a managed long-term care plan, and going forward, that plan would be responsible for Medicaid payments and Medicare cross-over claims. Prior to managed care enrollment, Medicaid payments and Medicare cross-over claims would be processed through fee-for-service.

Services

Question: What are the requirements for the Participate Direction Option (PDO) program that is taking the place of the CDC program? Do participants need to have an authorized Representation? Will participants have a case manager or consultant?
Answer: All LONG-TERM CARE (LTC) managed care enrollees who live in their own home or their family home have the choice, under the Participant Direction Option (PDO), to self-direct the following services listed on their care plan: adult companion care, attendant care, homemaker, intermittent and skilled nursing, and personal care. Enrollees will share employer responsibilities with the LONG-TERM CARE (LTC) health plan. Enrollees will be responsible for hiring, supervising, and firing their direct service workers. They can hire any qualified person they want to provide their services, including family members, friends, and neighbors. The LONG-TERM CARE (LTC) health plan will set the pay rate for the direct service workers. Enrollees may delegate their employer responsibilities to a representative. The LONG-TERM CARE (LTC) health plan will assign a case manager, specially trained in the Participate Direction Option (PDO), to train the participant and provide necessary ongoing technical assistance.

Question: How does medical managed care work with LONG-TERM CARE (LTC)?
Answer: Individuals dually eligible for Medicaid and Medicare will continue receiving their medical services primarily through Medicare. Medicaid recipients who do not have Medicare coverage will receive their medical services through the Medicaid State Plan until implementation of the Managed Medical Assistance Program.

Question: Once the Managed Medical Assistance component of the SMMC program rolls out next year, can
a member potentially have one plan for LONG-TERM CARE (LTC), one plan for MMC and one plan for Medicare?
Answer: If a managed care plan awarded a contract for Managed Medical Assistance (MMA) also has a contract with the Agency to provide long-term care services and a Medicare plan in the recipient's region, the recipient could choose to have one plan provide all necessary medical and long-term care services. It is possible that a member could choose to receive services from different plans. Each member will have a case manager who will be responsible for coordinating and tracking services for that member. If a member is dually eligible for Medicare and Medicaid, the member's case manager will assist that individual in navigating the system of care.

Question: Does the SMMC program reduce services available through Florida Medicaid?
Answer: No, health plans will be required to provide services at a level equivalent to the state plan. The Agency has requested authority for plans to customize their benefit packages to non-pregnant adults, vary cost sharing provisions, and provide coverage for additional services.

Question: For people with Medicare primary who are in a Medicare Advantage Plan (managed care) – how does the primary coordinate with Medicaid managed care plans?
Answer: All long-term care enrollees will have a case manager who will be responsible for communicating and coordinating services with appropriate treating providers, including the enrollee’s primary care provider.

Question: Will Managed Care Institutional Care Program (ICP) Medicaid have therapeutic or hospital leave bed holds?
Answer: Yes, managed long-term care plans will be responsible for covering bed hold days in nursing facilities as specified in the Florida Medicaid Nursing Facility Services Coverage and Limitations Handbook.

Other / Misc.

Question: Does the AHCA have an estimate of how many dual-eligibles will enroll in the Long-term Care expansion, or what percentage of that population they will make up?
Answer: The Agency currently serves approximately 85,000 Medicaid recipients in nursing facilities and the home and community-based waiver programs identified in the authorizing legislation for the long-term care managed care program. Approximately 95% of these recipients are dually eligible for both Medicare and Medicaid.