Aging and Disability Services

409.979 Eligibility.—

(2) ENROLLMENT OFFERS.—Subject to the availability of funds, the Department of Elderly Affairs shall make offers for enrollment to eligible individuals based on a wait-list prioritization. Before making enrollment offers, the agency and the Department of Elderly Affairs shall determine that sufficient funds exist to support additional enrollment into plans.

(a) A Medicaid recipient enrolled in one of the following Medicaid home and community-based services waiver programs who meets the eligibility criteria established in subsection (1) is eligible to participate in the long-term care managed care program and must be transitioned into the long-term care managed care program by January 1, 2018:

1. Traumatic Brain and Spinal Cord Injury Waiver.

2. Adult Cystic Fibrosis Waiver.

3. Project AIDS Care Waiver.

(b) The agency shall seek federal approval to terminate the Traumatic Brain and Spinal Cord Injury Waiver, the Adult Cystic Fibrosis Waiver, and the Project AIDS Care Waiver once all eligible Medicaid recipients have transitioned into the long-term care managed care program.

(3) WAIT LIST, RELEASE, AND OFFER PROCESS.— The Department of Elderly Affairs shall maintain a statewide wait list for enrollment for home and community-based services through the long-term care managed care program.

(a) The Department of Elderly Affairs shall prioritize individuals for potential enrollment for home and community-based services through the long-term care managed care program using a frailty-based screening tool that results in a priority score. The priority score is used to set an order for releasing individuals from the wait list for potential enrollment in the long-term care managed care program. If capacity is limited for individuals with identical priority scores, the individual with the oldest date of placement on the wait list shall receive priority for release.

1. Pursuant to s. 430.2053, aging resource center personnel certified by the Department of Elderly Affairs shall perform the screening for each individual requesting enrollment for home and community-based services through the long-term care managed care program. The Department of Elderly Affairs shall request that the individual or the individual's authorized representative provide alternate contact names and contact information.

2. The individual requesting the long-term care services, or the individual's authorized representative, must participate in an initial screening or rescreening for placement on the wait list. The screening or rescreening must be completed in its entirety before placement on the wait list.

3. Pursuant to s. 430.2053, aging resource center personnel shall administer rescreening annually or upon notification of a significant change in an individual's circumstances for an individual with a high priority score. Aging resource center personnel may administer rescreening annually or upon notification of a significant change in an individual's circumstances for an individual with a low priority score.

4. The Department of Elderly Affairs shall adopt by rule a screening tool that generates the priority score and shall make publicly available on its website the specific methodology used to calculate an individual's priority score.

(b) Upon completion of the screening or rescreening process, the Department of Elderly Affairs shall notify the individual or the individual's authorized representative that the individual has been placed on the wait list, unless the individual has a low priority score. The Department of Elderly Affairs must maintain contact information for each individual with a low priority score for purposes of any future rescreening. Aging resource center personnel shall inform individuals with low priority scores of community resources available to assist them and inform them that they may contact the aging resource center for a new assessment at any time if they experience a change in circumstances.

(c) If the Department of Elderly Affairs is unable to contact the individual or the individual's authorized representative to schedule an initial screening or rescreening, and documents the actions taken to make such contact, it shall send a letter to the last documented address of the individual or the individual's authorized representative. The letter must advise the individual or his or her authorized representative that he or she must contact the Department of Elderly Affairs within 30 calendar days after the date of the notice to schedule a screening or rescreening and must notify the individual that failure to complete the screening or rescreening will result in his or her termination from the screening process and the wait list.

(d) After notification by the agency of available capacity, the CARES program shall conduct a prerelease assessment. The Department of Elderly Affairs shall release individuals from the wait list based on the priority scoring process and prerelease assessment results. Upon release, individuals who meet all eligibility criteria may enroll in the long-term care managed care program.

(e) The Department of Elderly Affairs may terminate an individual's inclusion on the wait list if the individual:

1. Does not have a current priority score due to the individual's action or inaction;

2. Requests to be removed from the wait list;

3. Does not keep an appointment to complete the rescreening without scheduling another appointment and has not responded to three documented attempts by the Department of Elderly Affairs to contact the individual;

4. Receives an offer to begin the eligibility determination process for the long-term care managed care program; or

5. Begins receiving services through the long-term care managed care program.

An individual whose inclusion on the wait list is terminated must initiate a new request for placement on the wait list, and any previous priority considerations must be disregarded.

(f) Notwithstanding this subsection, the following individuals are afforded priority enrollment for home and community-based services through the long-term care managed care program and do not have to complete the screening or wait-list process if all other long-term care managed care program eligibility requirements are met:

1. An individual who is 18, 19, or 20 years of age who has a chronic debilitating disease or condition of one or more physiological or organ systems which generally make the individual dependent upon 24-hour-per-day medical, nursing, or health supervision or intervention.

2. A nursing facility resident who requests to transition into the community and who has resided in a Florida-licensed skilled nursing facility for at least 60 consecutive days.

3. An individual who is referred by the Department of Children and Families pursuant to the Adult Protective Services Act, ss. 415.101-415.113, as high risk and who is placed in an assisted living facility temporarily funded by the Department of Children and Families.

(g) The Department of Elderly Affairs and the agency may adopt rules to implement this subsection.

409.979 Eligibility.—

(2) PRE-ENROLLMENT OFFERS.—Subject to the availability of funds, the Department of Elderly Affairs shall make offers for enrollment to eligible individuals based on a pre-enrollment list prioritization. Before making enrollment offers, the agency and the Department of Elderly Affairs shall determine that sufficient funds exist to support additional enrollment into plans.

(3) PRE-ENROLLMENT LIST, RELEASE, AND OFFER PROCESS.— The Department of Elderly Affairs shall maintain a statewide pre-enrollment list for enrollment for home and community-based services through the long-term care managed care program.

(a) The Department of Elderly Affairs shall prioritize individuals for potential enrollment for home and community-based services through the long-term care managed care program using a frailty-based screening tool that results in a priority score. The priority score is used to set an order for releasing individuals from the pre-enrollment list for potential enrollment in the long-term care managed care program. If capacity is limited for individuals with identical priority scores, the individual with the oldest date of placement on the pre-enrollment list shall receive priority for release.

1. Pursuant to s. 430.2053, aging and disability resource center personnel certified by the Department of Elderly Affairs shall perform the screening for each individual requesting enrollment for home and community-based services through the long-term care managed care program. Aging and disability resource center personnel shall place on and release from the pre-enrollment lists clients eligible for the Alzheimer's Disease Initiative, community care for the elderly, home care for the elderly, and the Statewide Medicaid Managed Care Long-term Care program. The Department of Elderly Affairs shall request that the individual or the individual's authorized representative provide alternate contact names and contact information.

2. The individual or the individual's authorized representative must participate in an initial screening or rescreening for placement on the pre-enrollment list. The screening or rescreening must be completed in its entirety before placement on the pre-enrollment list.

3. Pursuant to s. 430.2053, staff authorized and certified by the Department of Elderly Affairs shall administer rescreening annually or upon notification of a significant change in an individual's circumstances for an individual with a high priority score. Aging and disability resource center personnel may administer rescreening annually or upon notification of a significant change in an individual's circumstances for an individual with a low priority score.

4. The Department of Elderly Affairs shall adopt by rule a screening tool that generates the priority score and shall make publicly available on its website the specific methodology used to calculate an individual's priority score.

(b) Upon completion of the screening or rescreening process, the Department of Elderly Affairs shall notify the individual or the individual's authorized representative that the individual has been placed on the pre-enrollment list, unless the individual has a low priority score. The Department of Elderly Affairs must maintain contact information for each individual with a low priority score for purposes of any future rescreening. Aging and disability resource center personnel shall inform individuals with low priority scores of community resources available to assist them and inform them that they may contact the aging and disability resource center for a new assessment at any time if they experience a change in circumstances.

(c) If the Department of Elderly Affairs is unable to contact the individual or the individual's authorized representative to schedule an initial screening or rescreening, and documents the actions taken to make such contact, it shall send a letter to the last documented address of the individual or the individual's authorized representative. The letter must advise the individual or his or her authorized representative that he or she must contact the Department of Elderly Affairs within 30 calendar days after the date of the notice to schedule a screening or rescreening and must notify the individual that failure to complete the screening or rescreening will result in his or her termination from the screening process and the pre-enrollment list.

(d) After notification by the agency of available capacity, the Department of Elderly Affairs shall release individuals from the pre-enrollment list based on the priority scoring process. The aging and disability resource center shall conduct a prerelease assessment. Upon release, individuals who meet all financial and medical eligibility criteria may enroll in the long-term care managed care program.

(e) The Department of Elderly Affairs may terminate an individual's inclusion on the pre-enrollment list if the individual:

1. Does not have a current priority score due to the individual's action or inaction;

2. Requests to be removed from the pre-enrollment list;

3. Does not keep an appointment to complete the rescreening without scheduling another appointment and has not responded to three documented attempts by the Department of Elderly Affairs to contact the individual;

4. Receives an offer to begin the eligibility determination process for the long-term care managed care program; or

5. Begins receiving services through the long-term care managed care program.

An individual whose inclusion on the pre-enrollment list is terminated must initiate a new request for placement on the pre-enrollment list, and any previous priority considerations must be disregarded.

(f) Notwithstanding this subsection, the following individuals are afforded priority enrollment for home and community-based services through the long-term care managed care program and do not have to complete the screening or pre-enrollment list process if all other long-term care managed care program eligibility requirements are met:

1. An individual who is 18, 19, or 20 years of age who has a chronic debilitating disease or condition of one or more physiological or organ systems which generally make the individual dependent upon 24-hour-per-day medical, nursing, or health supervision or intervention.

2. A nursing facility resident who requests to transition into the community and who has resided in a Florida-licensed skilled nursing facility for at least 60 consecutive days.

3. An individual who is referred by the Department of Children and Families pursuant to the Adult Protective Services Act, ss. 415.101-415.113, as high risk and who is placed in an assisted living facility temporarily funded by the Department of Children and Families.

(g) The Department of Elderly Affairs and the agency may adopt rules to implement this subsection.

409.983 Long-term care managed care plan payment.—In addition to the payment provisions of s. 409.968, the agency shall provide payment to plans in the long-term care managed care program pursuant to this section.

(4) The initial assessment of an enrollee's level of care shall be made by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, which shall assign the recipient into one of the following levels of care:

(a) Level of care 1 consists of recipients residing in or who must be placed in a nursing home.

(b) Level of care 2 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, and who require extensive health-related care and services because of mental or physical incapacitation.

(c) Level of care 3 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, who have a limited need for health-related care and services and are mildly medically or physically incapacitated.

The agency shall periodically adjust payment rates to account for changes in the level of care profile for each managed care plan based on encounter data.

409.983 Long-term care managed care plan payment.—In addition to the payment provisions of s. 409.968, the agency shall provide payment to plans in the long-term care managed care program pursuant to this section.

(4) The initial assessment of an enrollee's level of care shall be reviewed or performed by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, which shall assign the recipient into one of the following levels of care:

(a) Level of care 1 consists of recipients residing in or who must be placed in a nursing home.

(b) Level of care 2 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, and who require extensive health-related care and services because of mental or physical incapacitation.

(c) Level of care 3 consists of recipients at imminent risk of nursing home placement, as evidenced by the need for the constant availability of routine medical and nursing treatment and care, who have a limited need for health-related care and services and are mildly medically or physically incapacitated.

The agency shall periodically adjust payment rates to account for changes in the level of care profile for each managed care plan based on encounter data.