Florida Medicaid - Senior Resource Alliance

Transcription

Florida
Medicaid
Assistive Care Services and Assisted Living
for the Elderly Waiver Services
Coverage and Limitations Handbook
Agency for Health Care Administration
JEB BUSH, GOVERNOR
ALAN LEVINE, SECRETARY
February 16, 2006
Dear Assistive Care Services and Assisted Living for the Elderly Waiver Services Providers:
We have discovered an error in the Florida Medicaid Assistive Care Services and Assisted
Living for the Elderly Waiver Services Coverage and Limitations Handbook. The procedure
codes in Appendix A, Assistive Care Services Procedure Code Table and Fees, and Appendix F
Assistive Living for the Elderly Waiver Services Procedure Code Table and Fees are obsolete.
Attached are corrected pages with the current procedure codes.
Please replace the following pages in the handbook with the attached revised pages.
Updated Pages
Update Log
Appendix A, page A-1
Appendix F, page F-1
Please contact your area Medicaid office if you have any questions. The area Medicaid offices’
phone numbers and addresses are available on the Agency’s website at
http://ahca.myflorida.com. Click on Medicaid, and then on Area Offices. They are also listed in
Appendix C of the Florida Medicaid Provider General Handbook. All the Medicaid handbooks
are available on the Florida Medicaid Provider Handbook and Resource Library CD-ROM and
on the Medicaid fiscal agent’s website at http://floridamedicaid.acs-inc.com. Click on Provider
Support, and then on Handbooks.
We appreciate the services that you provide to Florida’s Medicaid recipients.
Sincerely,
Beth Kidder
Chief, Bureau of Medicaid Services
2727 Mahan Drive y Mail Stop 8
Tallahassee, FL 32308
Visit AHCA online at
http://ahca.myflorida.com
UPDATE LOG
ASSISTIVE CARE SERVICES AND
ASSISTED LIVING FOR THE ELDERLY WAIVER SERVICES
COVERAGE AND LIMITATIONS HANDBOOK
How to Use the Update Log
Introduction
Changes to the handbook will be sent out as handbook updates. An
update can be a change, addition, or correction to policy. It may be
either a pen and ink change to the existing handbook pages or
replacement pages.
It is very important that the provider read the updated material and file
it in the handbook as it is the provider’s responsibility to follow correct
policy to obtain Medicaid reimbursement.
Explanation of the
Update Log
The provider can use the update log to determine if all handbook
updates have been received.
Update No. is the number that appears on the front of the update.
Effective Date is the date that the update is effective.
Instructions
1. Make the pen and ink changes and file new or replacement pages.
2. File the cover page and pen and ink instructions from the update in
numerical order after the log.
If an update is missed, write or call the Medicaid fiscal agent at the
address given in Appendix C of the Florida Medicaid Provider
General Handbook.
UPDATE NO.
July 2001 New Handbook
Oct 2003 Update Pages
EFFECTIVE DATE
July 2001
October 2003
ASSISTIVE CARE SERVICES AND
Table of Contents
Chapter and Topic
Page
Introduction
Handbook Use and Format..........................................................................................ii
Characteristics of the Handbook .................................................................................iii
Handbook Updates ......................................................................................................iv
Part I – Assistive Care Services
Chapter 1 - Purpose, Background, and Program Specific Information
Overview .....................................................................................................................1-1
Description and Purpose .............................................................................................1-2
Provider Qualifications and Responsibilities ..............................................................1-4
Chapter 2 - Covered Services, Limitations, and Exclusions
Overview .....................................................................................................................2-1
Requirements To Receive Services.............................................................................2-1
Covered Service ..........................................................................................................2-5
Assessments for ALF and AFCH Residents ...............................................................2-6
Service Plans for ALF and AFCH Residents ..............................................................2-7
Assessments for RTF Residents ..................................................................................2-11
Treatment Plans for RTF Residents ............................................................................2-13
Leave of Absence and Discharge ................................................................................2-14
Termination of Services ..............................................................................................2-15
Chapter 3 - Procedure Codes and Fees
Overview .....................................................................................................................3-1
Reimbursement Information........................................................................................3-1
Appendix A: Procedure Code Table and Fees ...........................................................A-1
Appendix B: Appeal Rights and Fair Hearing Process ..............................................B-1
Appendix C: Certification of Medical Necessity Form..............................................C-1
Appendix D: ACS Service Plan Form and Instructions .............................................D-1
Appendix E: Resident Service Log and Instructions .................................................E-1
Part II – Assisted Living for the Elderly Waiver Services
Chapter 4 – Purpose, Background, and Program Specific Information
Overview .....................................................................................................................4-1
Description and Purpose..............................................................................................4-1
Provider Qualifications and Responsibilities ..............................................................4-2
Chapter 5 - Covered Services, Limitations, and Exclusions
Overview .....................................................................................................................5-1
Requirements to Receive Services ..............................................................................5-1
Case Management Requirements ................................................................................5-4
Case Management Documentation..............................................................................5-5
Plan of Care .................................................................................................................5-6
Plan of Care Review and Reassessment......................................................................5-9
ALE Waiver and Assistive Care Covered Services ....................................................5-9
Placement and Discharge ............................................................................................5-17
Termination of Services ..............................................................................................5-18
Chapter 6 – Procedure Codes and Fees
Overview .....................................................................................................................6-1
Reimbursement Information........................................................................................6-1
Appendix F: Procedure Code Table and Fees ............................................................F-1
Appendix G: Appeal Rights and Fair Hearing Process..............................................G-1
Assistive Care Services and Assisted Living for the Elderly Waiver Services
INTRODUCTION TO THE HANDBOOK
Overview
Introduction
This chapter introduces the format used to prepare the Medicaid
Reimbursement and Coverage and Limitations Handbooks and tells the
reader how to use the handbooks.
Background
The Coverage and Limitations Handbook explains covered services, their
limits and who is eligible to receive them. It is to be used with the
Reimbursement Handbook, which describes how to complete and file claims
for reimbursement by Medicaid.
Legal Authority
The Medicaid program is authorized by Title XIX of the Social Security Act
and Title 42, Code of Federal Regulations. The Florida Medicaid program
is authorized by Chapter 409, Florida Statutes (F.S.) and Chapter 59G,
Florida Administrative Code (F.A.C.).
Federal Regulations, Florida Statutes, and the Florida Administrative Code,
which deal with the purpose, implementation, and administration of each
Medicaid program, are cited for reference in each program Coverage and
Limitations Handbook.
In This Chapter
This chapter contains:
TOPIC
July 2001
PAGE
Handbook Use and Format
ii
Characteristics of the Handbook
iii
Handbook Updates
iv
i
Handbook Use and Format
Purpose
The purpose of the Medicaid handbooks is to furnish the Medicaid provider
with the policies and procedures needed to receive reimbursement for
covered services provided to eligible Florida Medicaid recipients.
The handbooks provide descriptions and instructions on how and when to
complete forms, letters or other documentation.
Provider
The term provider is used to describe any entity, facility, person or group
who is enrolled in the Medicaid program and renders services to Medicaid
recipients and bills Medicaid for services.
Recipient
The term recipient is used to describe an individual who is eligible for
Medicaid.
Coverage and
Limitations
Handbook
Each service handbook is named for the service it describes and is referred
to as a “Coverage and Limitations Handbook.” A provider who furnishes
more than one type of service will have more than one coverage and
limitations handbook.
Reimbursement
Handbook
Each reimbursement handbook is named for the claim form that it describes.
A provider who bills on more than one type of claim form will have more
than one reimbursement handbook.
Chapter Numbering
System
The first page of each chapter designates the chapter number. The chapter
number will appear as the first number of the page number at the bottom of
each page in the handbook.
Page Numbering
Pages are numbered consecutively by chapter. Page numbers follow the
chapter number found at the bottom of each page.
July 2001
ii
Handbook Use and Format, continued
White Space
The white space throughout a handbook is characteristic of the handbook
format style. It enhances readability and allows space for writing notes
during training and for on-the-job reference.
Characteristics of the Handbook
Format
The format used in this handbook represents a concise and consistent way of
displaying complex, technical material.
Information Block
One of the major features of the format is the information block, which
replaces the traditional paragraph. Blocks are separated by horizontal lines.
The block consists of one or more paragraphs or diagrams about a portion
of a subject. Each block is identified or named with a label.
Label
Labels or names are located in the left margin of each information block.
They describe the content or function of the block.
Labels provide key subject matter identification which facilitates scanning
and locating information quickly within a chapter or section within a chapter.
Note
Note: is used most frequently to refer the user to material located elsewhere
in a handbook that is pertinent to the subject being addressed within the
information block.
Note: also refers the user to other documents or policies contained in other
handbooks.
July 2001
iii
Characteristics of the Handbook , continued
Topic Roster
Each chapter contains a topic roster which lists the major subject areas
covered in the chapter and gives the page number where the subject can be
found. This topic roster serves as a table of contents for major sections
within each chapter.
Handbook Updates
How Changes Are
Updated
The Medicaid handbooks will be updated as needed.
Lengthy changes or multiple changes that occur at the same time will be sent
on replacement pages.
Brief changes will be sent as pen and ink updates. The pen and ink updates
will be incorporated on replacement pages the next time replacement pages
are produced.
Update Log
A page designated as the log will accompany handbook updates. This log
serves as a reference for the provider to be sure that each update has been
received.
An “Update No.” will be indicated in the first column on the update log. The
second column is titled the “Effective Date” and indicates the date that the
update is effective.
Numbering Update
Pages
July 2001
Updated replacement pages will have the same number as the page they are
replacing. If additional pages are required, the new pages will carry the
same number as the proceeding replacement page with an alphabetic
character in ascending order.
iv
Handbook Updates, continued
Effective Date of
New Material
The month and year that the new material is effective will appear in the
bottom left corner of each page. The provider can check this date to
ensure that the material being used is the most current and up to date.
If an information block has an effective date that is different from the
effective date on the bottom of the page, the effective date for the
information block will be included in the label.
Identifying New
Information
New material will be indicated by vertical, gray-shaded lines. The
following information blocks give examples of how new labels, new
information blocks, and new or changed material within an information
block will be indicated.
New Label
A new label for an existing information block will be indicated by a
vertical line to the left and right of the label only.
New Label/New
Information Block
A new label and a new information block will be identified by a vertical
line to the left of the label and to the right of the information block.
New Material in
an Existing
Information Block
New or changed material within an existing information block will be
indicated by a vertical line to the left and right of the information block.
New or Changed
Paragraph
A paragraph within an information block that has new or changed
material will be indicated by a vertical line to the left and right of the
paragraph.
Paragraph with new material.
July 2001
v
This page intentionally left blank
July 2001
vi
PART I
CHAPTER 1
ASSISTIVE CARE SERVICE
PURPOSE, BACKGROUND, AND PROGRAM SPECIFIC INFORMATION
Overview
Introduction
This chapter describes Florida Medicaid’s Assistive Care Services program,
specifies the authority regulating assistive care services, the purpose of the
program, and provider qualifications and responsibilities.
Information regarding Assistive Care Services covered by Florida Medicaid
can be found on the Agency for Health Care Administration’s (AHCA)
Internet site. The address is www.fdhc.state.fl.us, click on Medicaid,
then click on Assistive Care Services.
Legal Authority
State plan Medicaid service programs, are authorized under Section 1902 of
the Social Security Act and governed by Title 42, Code of Federal
Regulations (C.F.R.), Part 440.167.
The Florida Medicaid assistive care service is authorized by Chapter 409,
Florida Statutes (F.S.) and the Florida Administrative Code (F.A.C.),
Chapter 59G-4.025. and the handbook is incorporated in Chapter 59G8.200.
In This Chapter
TOPIC
July 2001
PAGE
Description and Purpose
1-2
Provider Qualifications and Responsibilities
1-4
1-1
Assistive Care
Service Description
The Assistive Care Services program is a Medicaid state plan service that
provides care to eligible recipients requiring an integrated set of services on a
24-hour per day basis. Eligible residents must reside in a qualified assisted
living facility (ALF), adult family care home (AFCH) or residential treatment
facility (RTF) and be provided scheduled and unscheduled care on a 24hour per day basis when needed by the resident.
Assistive care service recipients must demonstrate functional limitations that
make it medically necessary for them to live in congregate living facilities and
have access to integrated assistive care services on a 24-hour per day basis.
Purpose
The purpose of the Assistive Care Service program is to promote and
maintain the health of eligible recipients and to minimize the effects of illness
and disability in order to delay or prevent institutionalization.
Medicaid
Reimbursement
This handbook is intended for use by ALFs, AFCHs and RTFs who provide
assistive care services to eligible recipients. It must be used in conjunction
with the Medicaid Provider Reimbursement Handbook, HCFA-1500 and
Child Health Check-Up 221, which contains information about the
Medicaid program in general, as well as specific procedures for submitting
claims for payment.
Personal Needs
Allowance (PNA)
All recipients of Assistive Care Services must be allowed to keep from their
personal income an amount equal to the personal needs allowance under the
Optional State Supplementation (OSS) Program. (Chapter 65A-2.036,
F.A.C.) Currently the PNA is $54.00 per month. The PNA must be
available to the resident by the tenth day of each month. The facility may
assist the resident in managing these personal funds, but may not restrict how
the resident chooses to spend the PNA funds.
July 2001
1-2
Description and Purpose, continued
Medicaid Fraud and
Abuse
Consult Chapter 5 of the Medicaid Provider Reimbursement Handbook
HCFA 1500 and Child Health Check-Up 221, for information regarding
Medicaid policy on provider abuse and fraud and Medicaid’s recoupment
policies.
Administrative
Responsibility
The assistive care service program is jointly administered by the Agency for
Health Care Administration (AHCA), and the Department of Children and
Families (DCF).
•
•
Area Medicaid
Offices
AHCA is responsible for assuring compliance with federal program
requirements, developing Medicaid policy, program operations, and for
reimbursing Medicaid providers.
DCF is responsible for determining the recipient’s OSS and Medicaid
eligibility.
Area Medicaid offices are located throughout Florida to assist Medicaid
service providers with questions and problems.
Note: See Appendix C of the Medicaid Provider Reimbursement
Handbook, HCFA-1500 and Child Health Check-Up 221, for a list of
area Medicaid office addresses and telephone numbers.
July 2001
1-3
General Assistive
Care Service
Provider
Qualifications
Three types of residences may qualify as Medicaid Assistive Care Service
providers:
•
Assisted living facilities (ALFs) licensed pursuant to Chapter 400, Part
III, FS;
•
Adult family care homes (AFCHs) licensed pursuant to Chapter 400,
Part VII, FS; and
•
Mental Health Residential treatment (RTFs) facilities licensed pursuant to
Section 394.875 FS.
In addition, an ACS provider must meet the following qualifications:
•
Is not an institution for mental diseases (IMD) as defined in
42 CFR § 435.1009(2);
Special Assistive
Care Provider
Requirements for
RTFs
July 2001
•
Provide on-site care to residents seven days a week;
•
Does not have a contract with a state agency that provides
reimbursement for assistive care services as defined in this
handbook;
•
Will not claim reimbursement for assistive care services for any
recipient receiving a payment for personal care through the Optional
State Supplementation (OSS) Program under Chapter 409.212, FS.
Along with their Medicaid Provider application, RTFs must submit two
additional forms:
•
•
Provider Self-Certification Form (AHCA From 5000-3200) and
Roster of OSS recipients.
1-4
Provider Qualifications and Responsibilities, continued
ALF Facility
Administrators
Qualifications
ALF facility administrators and managers must:
•
Satisfy requirements of Chapter 400.425, F.S. and the training
requirements of Chapter 58A-5.019, F.A.C.
Documentation of these qualifications must be maintained in the facility
personnel files and must be made available to AHCA monitoring staff or its
designees upon request.
ALF Direct
Care Staff
Qualifications
ALF direct care staff must have the following qualifications:
•
•
Satisfy the qualifications for ALF Direct Care Staff in Chapter 58A5.019, F.A.C. and the training requirements of Chapter 58A-5.0191,
F.A.C., and;
Documentation delegating the authority to sign ACS service plans to
ALF Direct Care Staff, if the administrator does not perform this
function.
Documentation of these qualifications must be maintained in the staff
member’s personnel file at the facility and must be made available to AHCA
monitoring staff and surveyor staff upon request.
Adult Family
Care Home
(AFCH) Provider,
Relief Person and
Staff Qualifications
AFCH providers, relief persons and staff must satisfy the following
qualifications:
•
Satisfy the requirements of Chapter 400.621, F.S. and
Chapter 58A-14.008, F.A.C.
personnel records and be made available to AHCA monitoring or surveyor
staff upon request.
July 2001
1-5
RTF Manager
and Staff
Qualifications
All RTF managers and staff must have at least the following qualifications:
•
•
Comply with Chapter 394, F.S. and Chapter 65E-4.019, F.A.C.; and
Documentation delegating the authority to sign ACS service plans to
RTF Direct Care Staff, if the RTF manager does not perform this
function.
personnel records and be made available to AHCA monitoring or surveyor
staff upon request.
Assistive Care
Provider
Responsibilities
The assistive care provider has the responsibility to:
1. Αssist prospective ACS applicants with applications for Medicaid
services, if they have not already been determined eligible for Medicaid;
2. Advise the ACS applicant and recipient of their fair hearing rights and the
grievance process;
3. Arrange for health assessments annually or when significant changes
occur in an ACS resident’s condition;
4. Develop and implement a service plan for each recipient;
5. Document that the recipient is receiving services from the facility staff on
each day for which ACS is billed;
6. Maintain up-to-date recipient case records in accordance with the
handbook and applicable licensure requirements;
7. Coordinate other services provided to the consumer, such as hospice,
waiver, and Medicare (including providing copies of the resident contract
to the waiver case manager or hospice coordinator in order to
coordinate the service plan and avoid service duplication);
July 2001
1-6
Assistive Care
Provider
Responsibilities,
continued
July 2001
8. Provide an integrated set of services on a 24-hour basis;
9. Provide all ACS recipients with a personal needs allowance (PNA) in an
amount equal to that set by Chapter 65A-2.036, F.A.C.;
10. Comply with all provisions of the Medicaid Provider Agreement;
11. Cooperate with Medicaid monitoring staff or its designated
representatives;
12. Comply with all licensure requirements applicable to the facility; and
13. Comply with the requirements of Rule 59G-8.200 (15), F. A. C. and the
Assistive Care Services and Assisted Living for the Elderly Coverage
and Limitations Handbook.
1-7
Assistive Care Services and Assisted Living for the Elderly Wavier Services
PART I
CHAPTER 2
ASSISTIVE CARE SERVICES
COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS
Overview
Introduction
This chapter describes the services covered under the Florida Medicaid
Assistive Care Service (ACS) program. It also describes the requirements
for service provision, service limitations, and exclusions.
In This Chapter
TOPIC
PAGE
Requirements To Receive Services
2-1
Covered Service
2-5
Assessments for ALF and AFCH Residents
2-6
Service Plans for ALF and AFCH Residents
2-7
Assessments for RTF Residents
2-11
Treatment Plans for RTF Residents
2-13
Leave of Absence and Discharge
2-14
Termination of Services
2-15
Requirements to Receive Services
Introduction
July 2001
Medicaid may reimburse for assistive care services provided in qualified
Assisted Living Facilities (ALFs), Adult Family Care Homes (AFCHs), and
Residential Treatment Facilities (RTFs) to eligible Medicaid recipients.
2-1
Assistive Care Service and Assisted Living for the Elderly Wavier Services
Requirements to Receive Services, continued
Medicaid
Application
Responsibilities
If an individual has not applied for and been determined eligible for Medicaid
at the time Assistive Care Services (ACS) are needed, the individual must
submit a Request for Assistance (RFA) to the local service center of the
Department of Children and Families. Providers should assist individuals with
this process.
Note: See Appendix C of the Medicaid Provider Reimbursement
Handbook, HCFA-1500 and Child Health Check-Up 221 for a list of the
DCF district offices. A map of district offices is available on the Internet at
www.MyFlorida.com. Click on Directory, and then click on Children and
Families, then click on Economic Services, and then click on Service Center
of desired county.
Who Can Receive
ACS Services
To receive assistive care services, recipients in this program must be at least
18 years of age or older and meet the following requirements:
1. Be Medicaid eligible;
2. Have a health assessment completed by a physician or other licensed
practitioner of the healing arts acting within the scope of their practice
under state law which indicates the medical necessity of assistive care
services;
3. Be determined to need at least two service components of the
assistive care service;
4. Reside in an ACS-enrolled ALF, RTF, or AFCH; and
5. Not participate in any Medicaid managed care program such as the
Eldercare HMO, or the Long-Term Care Community Pilot Project
where the capitated payment is designed to cover all Medicaid
services.
Assisted Living for the Elderly (ALE) waiver recipients can receive ASC
services provided the waiver and ACS component services are not
duplicative and appear on the ALE service plans.
Note: See Part II of this handbook for information on the ALE waiver
program requirements.
July 2001
2-2
Who Cannot
Receive ACS
Services
Institutionalized Medicaid recipients residing in institutions such as nursing
facilities, state mental hospitals, institutions of mental disease, or intermediate
facilities for the developmentally disabled cannot receive ACS.
Income Guidelines
for Assistive Care
Service (ACS)
Applicants
The income guidelines for facilities with potential assistive care service
residents are as follows:
Maximum Income for:
OSS recipient
Medicaid (MEDS-AD) (unless eligible for
Amount:
$609.40 per month
$665.00 per month
Medicaid under ICP or Medicaid Waiver)
Home and Community-Based Waiver
$1,593.00 per month (ICP
income limit)
Residents with monthly incomes at or below $609.40 are eligible for both
OSS and ACS payments.
Residents with monthly incomes between $609.41 and $665.00 can receive
ACS provided other Medicaid eligibility requirements are met.
Residents with monthly incomes between $665.01 and $1,593.00 are not
eligible for ACS alone. These residents may be eligible for ACS through the
ALE waiver as described in Part II of this handbook.
If an individual is eligible for Medicaid through the Medically Needy Program,
he or she is not eligible for ACS.
Note: Income limits are revised as federal poverty levels are updated.
Please check the SSI-Related Fact Sheet on the Internet at
www.fdhc.state.fl.us for the latest updates. Click on Medicaid. There is a
link to the SSI-Related Fact Sheet on the Medicaid page. Information about
income limits is also available from the DCF service centers.
July 2001
2-3
Functional and
Health Criteria
Eligible Medicaid recipients must have at least the following functional
capabilities:
• Ambulatory, with or without assistance;
• Does not exhibit chronic inappropriate behavior which disrupts the
facility’s operations or is harmful to self or others;
• Is capable of taking his or her medication with assistance;
• Does not have any stage 3 or 4 pressure sores; and
• Does not require 24-hour nursing supervision.
Definition of
Medical Necessity
Chapter 59G-1.010, F.A.C., defines medical necessity as medical or allied
care, or services furnished or ordered that must:
•
•
•
•
•
Need for Assistive
Care Services
July 2001
Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;
Be individualized, specific, and consistent with symptoms or confirmed
diagnosis of the illness or injury under treatment, and not in excess of the
patient’s needs;
Be consistent with generally accepted professional medical standards as
determined by the Medicaid program, and not experimental or
investigational;
Be reflective of the level of service that can be safely furnished and for
which no equally effective and more conservative or less costly treatment
is available; and
Be furnished in a manner not primarily intended for the convenience of the
recipient, the recipient’s caregiver, or the provider.
A recipient of ACS must require an integrated set of services on a 24-hour
basis and must have a health assessment establishing the medical necessity of
at least two of the four service components described below.
2-4
Covered Service
Assistive Care
Services
W-9659
Assistive care services are an array of services provided on a daily basis by
or through ALFs, AFCHs, or RTFs.
The following components may be included in the assistive care service plan:
•
Health support;
•
Assistance with activities of daily living (ADLs);
•
Assistance with instrumental activities of daily living (IADLs); and
•
Assistance with self-administration of medication.
The criteria for provision of each component are explained below.
Health Support
Component
Health support is defined as requiring the provider to:
•
•
•
Assistance with
Activities of Daily
Living (ADLs)
Component
July 2001
Observe the recipient’s whereabouts and well-being on a daily basis;
Remind the recipient of any important tasks on a daily basis; and
Record and report any significant changes in the recipient’s appearance,
behavior, or state of health to the recipient’s health care provider,
designated representative, or case manager.
Assistance with activities of daily living (ADLs) is defined as providing
assistance with one or more of the following activities: individual assistance
with ambulating, transferring, bathing, dressing, eating, grooming, and
toileting. At least one service component must be required daily.
2-5
Covered Service, continued
Assistance with
Instrumental Acts of
Daily Living
(IADLs)
Component
Assistance with instrumental activities of daily living (IADLs) is defined as
providing intensive assistance with one or more of the following activities:
individual assistance with shopping for personal items, making telephone calls,
and managing money
Assistance with
Self-Administration
of Medication
Component
Assistance with self-administration of medication is defined assistance with or
supervision of self-administration of medication at least daily in accordance
with licensure requirements applicable to the facility type.
Implementation of
Assistive Care
Services
Assistive care services for an eligible recipient may be provided and billed
from the first day of need for services as long as service planning is under way
and completed as required.
Assessments for ALF and AFCH Residents
Initial Health
Assessment
If the need and eligibility for ACS commence with admission to the ALF and
AFCH, the initial assessment requirement is the same as for the facility type.
•
ALF Residents
Chapter 58A-5.0181 (2), F.A.C.
• AFCH Residents Chapter 58A-14.0061, F.A.C.
If the need and eligibility for ACS commence after admission to the ALF and
AFCH, an assessment following the same procedure as for re-assessment
must be completed prior to billing for ACS.
However, if the admission does not document the need for at least two of the
four ACS components, additional documentation must be obtained from the
health care provider. The optional Certification of Medical Necessity form
may be used for this purpose.
Note: See Part I, Appendix C for a copy of the form and instructions.
July 2001
2-6
Assessments for ALF and AFCH Residents, continued
Re-Assessment
Recipients receiving Assistive Care Services must have a complete
assessment at least annually or sooner if a significant change in the recipient’s
condition occurs. An annual assessment must be completed no more than
one-year plus fifteen days after the last assessment. An assessment triggered
by a significant change must be completed no more than fifteen days after the
significant change. The assessment must be completed by physician or
physician assistant or advanced registered practitioner. The assessment must
document the need for at least two of the four Assistive Care Service
components.
Note: Either the DOEA Form 1823 for ALF residents, the DOEA Form
1110 for AFCH residents or the optional Certification of Medical Necessity
form in Appendix C must be used for this purpose.
Significant Change
Chapter 58A-5.0131, F.A.C., defines significant change as a sudden or
major shift in behavior or mood, or deterioration in health status such as
unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure
sore. Ordinary day-to day fluctuations in functioning and behavior, a shortterm illness such as a cold, or the gradual deterioration in the ability to carry
out the activities of daily living that accompanies the aging process are not
considered significant changes.
Service Plans for ALF and AFCH Residents
Service Plans
July 2001
Every ACS recipient must have a service plan completed by the ACS service
provider. The ALF or AFCH is responsible for insuring the service plan is
developed and implemented.
2-7
Service Plans for ALF and AFCH Residents, continued
Service Plans,
continued
Required
Components
Service plan development involves six principles:
•
Individuality—addresses individual needs and preferences;
•
Accountability—specifies who is responsible for providing service;
•
Outcome orientation—identifies outcome of service;
•
Completeness—addresses all needs in the health assessment;
•
Input—resident must be consulted and agree with the plan; and
•
Staffing—guides staffing and facilities.
The service plan must be completed within 15 days after the initial health
assessment or reassessment, be in writing, and based on information
contained in the health assessment. The service plan must include:
•
•
•
•
•
•
•
Ιdentifying information (facility name, resident’s name, Medicaid
identification number, and date);
Services that address all needs identified in the health assessment;
Level of functioning and assistance needed;
Service provider;
Expected outcome of service;
Signed and dated by facility representative and resident, guardian or
designated representative; and
Updates when conditions change.
All needed ACS components must be specified in the recipient’s service plan.
July 2001
2-8
Acceptable Formats
Providers may use the optional form in Part I, Appendix D for documentation
of the service plans.
Provided the Service Plans contain the required components other acceptable
formats are:
• Community Living Support Plan,
• Medicaid Waiver Service Plan,
• Extended Congregate Care (ECC) Service Plan, and
• Provider’s Service Plan form with required components.
Note: Instructions for the optional form are in Part I, Appendix D.
Service Plan
Approval
The service plan must be completed no more than 15 days after the most
recent health assessment.
Service plan approval requires two signatures. For an ALF, the facility
administrator or person designated in writing by the administrator must sign.
For an AFCH, the provider who is the licensee must sign the service plan.
The service plan must also be signed by the resident except:
•
If the resident has a legal guardian, the guardian must sign the form on the
resident’s behalf.
•
If the resident has a representative designated in writing, the
representative may sign the form on the resident’s behalf.
The service plan is considered complete as of the last date signed by either
party.
July 2001
2-9
Service
Documentation
The ALF or AFCH must document that recipients received services in the
facility on each day for which ACS is billed. There is no required format for
such documentation.
Note: See Part I, Appendix E for the Optional Service Plan Log Form that
can be used for this purpose.
Service Plan Review
The service plan must be reviewed and updated to reflect the current needs
of the recipient. The service provider must monitor the service plan for
continuity of services and determine if changes in the recipient’s status
warrant changes in the service plan.
New Service Plan
A new service plan is required on an annual basis or sooner if a significant
change in the recipient’s condition occurs. The new service plan must be
completed no more than 15 days after the re-assessment required above.
ACS Records
In addition to records required by the applicable licensure standards, ACS
records that must be kept include:
• Copies of all eligibility documents, ( i.e., DCF OSS Notice of Case
Action, or Medifax strip)
• Health Assessment Forms (DOEA Form 1823 or 1110) and
reassessments forms;
• Assistive care service plan with updates, if any; and
• Copy of daily roster or other daily service documentation.
This documentation must be maintained at the facility, kept for at least five
years and be made available to Medicaid staff or its designated representative
upon request.
Note: See Chapter 2 of the Medicaid Provider Reimbursement
Handbook, HCFA 1500 and Child Health Check-Up 221, for additional
information about documentation requirements.
July 2001
2-10
ACS Record
Documentation
ACS documentation must be in ink and must be legible. No erasures or
white out are permitted. In case of an error, the ALF administrator or
designee, or AFCH provider must line through the error, initial and date it,
then make the correct entry.
Service Plan
Approval Impasse
and Fair Hearing
Rights
If the either the recipient, guardian or representative does not agree with the
service plan, and resolution cannot be reached, the service provider must
provide the recipient with instructions on the fair hearing process and assist
the recipient with preparing for the fair hearing. If the service provider has
any in-house grievance process, the recipient’s rights to a fair hearing cannot
be replaced by the in-house grievance process.
Note: See Part I, Chapter 3, Appendix B of this handbook for fair hearing
process information.
Assessments for RTF Residents
Initial Assessment
If the need and eligibility for ACS commence with admission to the RTF, the
initial assessment completed pursuant to Chapter 65E-4.016(9), F.A.C.,
meets the assessment requirement for ACS.
If the need and eligibility for ACS commence after admission to the RTF, an
assessment following the same procedure as for re-assessment must be
completed prior to billing for ACS.
July 2001
2-11
Assessments for RTF Residents, continued
Re-Assessment
Recipients receiving Assistive Care Services must have a complete
assessment at least annually or sooner if a significant change in the recipient’s
condition occurs. An annual assessment must be completed no more than
one-year plus fifteen days after the last assessment. An assessment triggered
by a significant change must be completed no more than fifteen days after the
significant change. The assessment must be completed by physician or
licensed mental health professional. The assessment must document the need
for at least two of the four Assistive Care Service components.
Note: See Part I, Appendix C for the optional Certification of Medical
Necessity form that may be used for this purpose.
Significant Change
July 2001
Chapter 58A-5.0131, F.A.C., defines significant change as a sudden or
major shift in behavior or mood, or deterioration in health status such as
unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure
sore. Ordinary day-to day fluctuations in functioning and behavior, a shortterm illness such as a cold, or the gradual deterioration in the ability to carry
out the activities of daily living that accompanies the aging process are not
considered significant changes.
2-12
Treatment Plans for RTF Residents
Treatment Plans for
RTF residents
Every ACS recipient must have a treatment plan completed, implemented and
reviewed according to the requirements of Chapter 65E-4.016(11), F.A.C.
Assistive care services for an eligible recipient may be provided and billed
from the first day of need for services as long as treatment planning is under
way and completed as required.
Service
Documentation for
RTF Residents
The RTF must document that residents received ACS on the day billed.
There is no required format for such documentation.
ACS Records
In addition to the records required by Chapter 65E-4.016 (11), F.A.C.,
ACS records must be kept for every recipient receiving ACS. ACS records
must include copies of all eligibility documents, i.e., OSS Notice of Case
Action or a copy of the Medifax strip.
Documentation applicable to ACS must be kept for at least five years and be
made available to Medicaid staff or its designated representatives upon
request.
Handbook, HCFA 1500 and Child Health Check-Up 221, for additional
information about documentation requirements.
July 2001
2-13
Leave of Absence and Discharge
Introduction
Medicaid recipients must reside in an ACS-enrolled facility in order to
receive ACS services. A recipient that is not a resident of an ACS-enrolled
facility will be denied ACS services even if all other eligibility criteria are met.
A recipient may be terminated from ACS, under some circumstances, when
moving from one facility to another. Recipients must be advised of their rights
to appeal these actions when they occur.
Leave of Absence
Recipients may leave the facility for more than 24 hours from time to time for
health or personal reasons. During such periods, Assistive Care Services are
not being provided and may not be billed.
ACS Discharge
Requirements
If the ALF, AFCH, or RTF representative initiates discharge of an ACS
recipient, the discharge must be done in accordance with the licensure
requirements applicable to the facility type.
Move to Another
ACS Provider
If the recipient requests to move or is moved from one ACS-enrolled facility
to another ACS-enrolled facility, the discharging facility representative will
assist in coordinating the placement, and the recipient will remain eligible to
receive ACS in the new facility.
The discharging facility may not bill for the day of discharge. The admitting
facility may bill for the day of admission.
Any time a change in facility is necessary for a recipient who receives
Optional State Supplemental (OSS) payments, the change must be
coordinated with the recipient’s DCF case manager.
July 2001
2-14
Leave of Abs ence and Discharge, continued
Move to a NonACS Provider or to
Unlicensed Setting
Changes in residence for a recipient who receives Optional State
Supplementation (OSS) payments must be coordinated with DCF. If it
appears that a nursing facility or other placement is necessary, the facility must
coordinate with the DCF case manager. If the resident participates in the
ALE Waiver, the local Department of Elder Affairs (DOEA) Comprehensive
Assessment and Review for Long Term Care Services (CARES) unit must
also be included in coordinating the plan to seek an appropriate placement.
The discharging facility may not bill ACS for the day of discharge.
Introduction
In most cases, ACS recipients must be given a written 10-day advance notice
of termination including their right to request a fair hearing.
Reasons for
Termination
Termination of ACS for any of the following reasons triggers the requirement
for a 10-day written notice:
•
•
•
•
•
Right to a Fair
Hearing
Loss of Medicaid eligibility;
The recipient’s condition no longer meets functional criteria;
The recipient voluntarily moves out of the facility to a non-ACS setting;
The recipient elects to stop assistive care services; or
Transfer to a non-participating ALF, RTF, or AFCH.
An ACS consumer has the right to appeal any action taken by the facility,
AHCA, DOEA, or DCF that adversely affects the recipient’s receipt of
services.
July 2001
2-15
PART I
CHAPTER 3
PROCEDURE CODES AND FEES
Overview
Introduction
This chapter provides and describes the procedure codes and approved
fees for the Assistive Care Services (ACS) program.
In this Chapter
TOPIC
PAGE
Reimbursement Information
3-1
Appendix A: Procedure Code Table and Fees
A-1
Appendix B: Appeal Rights and Fair Hearing Process
B-1
Appendix C: Optional Certification of Medical
Necessity Form
C-1
Appendix D: Optional ACS Service Plan From and
Instructions
D-1
Appendix E: Optional Resident Service Log and
Instructions
E-1
Introduction
July 2001
Medicaid reimburses for assistive care services procedure code based on
the Healthcare Common Procedure Coding System (HCPCS), Level III
procedure codes and locally assigned codes that have been approved by
CMS, formerly known as HCFA. Locally assigned codes are identified
by a “W” prefix.
3-1
Reimbursement Information, continued
Medicaid
Reimbursement
Claim Form
Assistive care services are billed on the HCFA-1500 and the 081 NonInstitutional claim forms. ALFs that do not participate in the ALE
Waiver program will use the HCFA-1500 claim form. ALE ALFs will
bill for ACS on the 081 Non-Institutional claim form.
Note: See the Medicaid Provider Reimbursement Handbook, HCFA1500 and Child Health Check-Up 221 and the Medicaid Provider
Reimbursement Handbook, 081-Non-Institutional, for specific procedures
for submitting claims for payment.
Procedure Code
Table
Billing for
Assistive Care
Services (ACS)
There is one reimbursable service in the assistive care service program.
The procedure code is found in Appendix A of this chapter. The service
and its components have been explained in Chapter 2 of this handbook.
The table gives:
•
The procedure code associated with the service;
•
The name of the service; and
•
The fee that Medicaid will reimburse for the service.
Assistive care service components are reimbursed at a single per diem
rate. Assistive care services providers are encouraged to bill at the end of
each calendar month. Claims for less than one calendar month will be
paid as billed. However, if a claim encompasses more than one calendar
month, the claim will be paid based only on the number of days billed for
the first month.
If the recipient is admitted to a hospital or a nursing facility from the ACS
facility, the last date of service (DOS) for ACS must be the day before the
recipient’s admission to the other facility.
July 2001
3-2
Billable Days for
ACS
Reimbursement will be made only for days the resident is eligible for and
is receiving services in the facility.
ACS providers cannot bill for those days a resident is not eligible for
Medicaid. In case of a resident who is not initially Medicaid-eligible, but
who applies for and is determined eligible for Medicaid, the provider can
bill for services from the effective date of Medicaid eligibility as shown
on the Notice of Case Action.
If the resident’s need and eligibility for ACS commence with admission
to the facility, reimbursement will be made from the day of admission.
Reimbursement will not be made for the day of discharge from the
facility.
Reimbursement will not be made when the recipient is absent for 24 hours
or more. In such cases, reimbursement will be made for the day the
resident returns, but not the day the resident leaves.
Note: See Chapter 3 of the Medicaid Provider Reimbursement Handbook,
HCFA-1500 and Child Health Check-Up 221 and the Medicaid Provider
Reimbursement Handbook, 081-Non-Institutional, for more information
regarding Medicaid recipient eligibility
Personal
Responsibility
July 2001
ACS providers agree to accept Medicaid payment as payment in full for
assistive care services. ACS providers cannot accept or solicit payments
from recipients or others for assistive care services. Facilities may accept
contributions from recipients and others for the cost of room, board, and
for services other than ACS.
3-3
APPENDIX A
PROCEDURE CODE TABLE AND FEES
CODE
T1020
DESCRIPTION OF SERVICE
ACS for Non-waiver recipients
UNIT
PER DIEM RATE
Daily
$9.28
Note for ALE Waiver providers use only: Procedure code T1020 U3 must be used to bill
for ACS services provided to ALE waiver recipients. For more information, consult
Chapter 6 of this handbook.
October 2003
A-1
PART I
APPENDIX B
APPEAL RIGHTS AND FAIR HEARING PROCESS
Fair Hearing Process
Right to a Fair
Hearing
An ACS recipient or applicant has the right to appeal any action taken by the
Agency for Health Care Administration (AHCA), Department of Children and
Families (DCF) or service providers that adversely affects the recipient’s receipt
of services.
ACS recipients must be given at least 10 calendar days advance written notice
of any suspension, reduction, or termination of services or program participation.
The advance notice must inform the ACS recipient of the right to a fair hearing.
Where to Apply for
a Hearing
Hearing requests must be sent to the DCF, Office of Hearing Appeals (OSIH),
1317 Winewood Boulevard, Building 5, Room 203, Tallahassee, Florida
32399-0700. The telephone number is (850) 488-1429.
How to Request a
Hearing
The ACS applicant, recipient, or authorized representative must request a
hearing within 90 days of the receipt of the written notification of the adverse
decision. ACS providers must offer assistance to recipients or applicants with
the fair hearing process.
Continuation of
Benefits
If the ACS applicant, recipient, or authorized representative requests a fair
hearing within 10 calendar days of the receipt of the notice of case action or
denial of service, ACS services must be reinstated at the level prior to the
adverse action.
If an ACS applicant or recipient requests a fair hearing and services are
reinstated to the prior level, the recipient might be requested to repay that
portion of the benefits that the hearing decision determines to be invalid. The
recipient must be given written notice of this responsibility.
July 2001
B-1
Assistive Care Services and Assisted Living for the Frail Elderly Waiver Services
Fair Hearing Process, continued
Reinstated Benefits
Reinstated or continued benefits must not be reduced or terminated prior to the
final hearing decision unless an additional cause for adverse action occurs while
the hearing decision is pending and the recipient fails to request a hearing after a
subsequent notice of adverse action.
The ACS provider must inform the recipient or authorized representative in
writing if benefits are reduced or terminated prior to the hearing decision.
Notification of Fair
Hearing Decisions
The hearing officer must send the applicant, recipient, or the authorized
representative a copy of the final order. In addition to describing the final
decision of the hearing, the final order explains:
•
•
The applicant, recipient, or authorized representative can request a judicial
review of the decision; and
The applicant, recipient, or authorized representative must pay the cost of
any judicial review.
Time Limit on
Hearing Decision
Federal law requires the final hearing decision must be made and communicated
to all involved parties within 90 calendar days of the hearing request.
Necessary Actions
to be Taken When
Appeal is Granted
Recipient benefit restoration or increases resulting from the final hearing decision
must begin within 10 calendar days of the date the local office is notified. Benefit
increases are effective based on the date specified by the hearings officer.
July 2001
B-2
PART I
APPENDIX C
The following page contains the Certification Of Medical Necessity For Medicaid Assistive Care
Services, an optional form. The form may be copied and used by providers to document medical
necessity.
July 2001
C-1
CERTIFICATION OF MEDICAL NECESSITY
FOR MEDICAID ASSISTIVE CARE SERVICES
Optional Form
Patient Name ________________________________________
DOB _____________
This is to certify that this patient is in need of an integrated set of assistive care services on a 24-hour
basis, including at least two of the following four service components (check as applicable):
____
Assistance with activities of daily living, which is defined as individual assistance
with ambulating, transferring, bathing, dressing, eating, grooming, and/or
toileting.
____
Assistance with instrumental activities of daily living, which is defined as
individual assistance with shopping for personal items, making telephone calls,
managing money, etc.
____
Health support, which is defined as observing the resident’s whereabouts and wellbeing; reminding the resident of any important tasks; and recording and
reporting any significant changes in appearance, behavior, or state of health to the health
care provider, designated representative, or case manager.
____
Assistance with self-administration of medication, which is defined as assistance
with or supervision of self-administration of medication as permitted by law.
HEALTH CARE PROVIDER (Not an employee of the ACS facility):
Typed Name
____________________________________________
License Number
____________________________________________
Signature
____________________________________________
Date Signed
____________________________________________
RETURN TO:
Facility Name & Address
____________________________________________________
Contact Person & Phone #
____________________________________________________
(AHCA Form 5000-3100B July 2001)
PART I
APPENDIX D
SERVICE PLAN FORM INSTRUCTIONS
The following pages contain an optional service plan form for assistive care services. The form may be
copied and used by providers to document the service plan.
General Information
ACTIVITIES
The activities on this form match those listed on the DOEA Health Assessment Form and the service
components on the Medical Necessity Certification. If the individual does not need any help with an
activity, check "Independent."
SERVICE
The level of service to be provided (supervision, assistance, total help, etc.) should match the need
shown on the Health Assessment7.
•
•
•
•
If the individual is independent in an activity, no other information need be provided for that
activity.
Providing supervision generally means reminding the individual to perform the activity, cueing the
individual as to how to do the activity, and monitoring that the individual completes the activity.
Providing assistance includes the tasks specified below under each activity on a daily basis.
Providing total help means that the provider performs the entire activity for the resident because
the resident is unable to perform any part of the activity for himself/herself.
PROVIDER
Show who will be responsible for providing the service needed. If the provider is other than Facility
Staff, specify who will be responsible, for example, daughter or home health agency.
EXPECTED OUTCOME
Specify how the resident is expected to function when the proper amount and type of care is provided;
the purpose of the service.
OTHER
Specify any other information about the service to be provided.
July 2001
D-1
Activities and Services
AMBULATION
Assistance includes: Providing physical support to enable the resident to move about within or outside
the facility. Physical support includes supporting or holding the resident's hand, elbow, or arm; holding
on to a support belt worn by the resident to assist in providing stability or direction while the resident
ambulates; or pushing the resident's wheelchair. The term does not include assistance with transfer.
Example of an expected outcome for Ambulation: Resident will be able to move about as needed.
BATHING
Assistance includes: Assembling towels, soaps, and other necessary supplies; helping the resident in
and out of the bathtub or shower; turning the water on and off; adjusting water temperatures, washing
and drying portions of the body which are difficult for the resident to reach; or being available while
the resident is bathing.
Example of an expected outcome for Bathing: Resident will be able to maintain body hygiene.
DRESSING
Assistance includes: Helping the resident to choose and to put on and remove clothing.
Example of an expected outcome for Dressing: Resident will be appropriately dressed.
TOILETING
Assistance includes: Assisting the resident to the bathroom, helping to undress, positioning on the
commode, and helping with related personal hygiene, including assistance with changing an adult brief.
Assistance with toileting includes assistance with routine emptying of a catheter or colostomy bag.
Example of an expected outcome for Toileting: Resident will maintain hygienic body functions
EATING
Assistance includes: Helping with cutting food, pouring beverages.
Example of an expected outcome for Eating: Resident will be able to consume an adequate and
appropriate diet.
GROOMING
Assistance includes: Physically helping the resident with shaving, with oral care, with care of the hair,
and with nail care.
Example of an expected outcome for Grooming: Resident's teeth, nails, hair, etc., will be adequately
groomed.
July 2001
D-2
TRANSFERRING
Assistance includes: Providing verbal and physical cueing or physical assistance or both while the
resident moves between bed and a standing position or between bed and chair or wheelchair.
Example of an expected outcome for Transferring: Resident will be able to move from bed to chair
and standing position or wheelchair as needed.
MEDICATIONS
If assistance is required with prescribed medications, the rule requirements for medication assistance
applicable to the provider type must be followed.
Non-daily medication supervision is not considered assistance.
Example of an expected outcome for Medications: Resident will take medications as prescribed, and
concerns will be communicated to health care provider.
MAKING TELEPHONE CALLS
Assistance includes: Dialing a number for a resident unable to do so.
Example of an expected outcome for Making Telephone Calls: Resident will be able to make
telephone calls as needed.
MANAGING MONEY
Assistance includes: Facility staff manages resident’s funds as representative payee or power of
attorney. Such assistance must comply with Section 400.424, FS.
Example of an expected outcome for managing money: Resident’s funds will be spent as desired by
the resident.
SHOPPING FOR PERSONAL ITEMS
Assistance includes: Purchasing items the resident chooses.
Example of expected outcome for shopping for personal items: Resident will be able to obtain desired
items.
USING AVAILABLE TRANSPORTATION
Assistance includes: Making arrangements for transportation needed by resident and supervising or
physically assisting resident into/out of the vehicle.
Escort includes: Providing or arranging for someone to accompany the resident while off-site.
Example of expected outcome for Using Available Transportation: Resident will safely access off-site
services and activities.
REMINDING RESIDENT OF IMPORTANT TASKS
Daily tasks could include meals, getting up and going to bed, attending activities, etc.
Example of expected outcome for Reminding Resident of Important Tasks: Resident will know to do
specified tasks.
July 2001
D-3
OBSERVING RESIDENT’S APPEARANCE AND WELL-BEING
Daily observation includes observing and interacting with resident each day, noting deviations from the
resident’s normal state of health and well-being, and contacting the health care provider, case
manager, or others as appropriate.
Example of expected outcome for Observing Resident’s Appearance and Well-being: Staff will be
aware of resident’s normal base line and will respond appropriate when deviations occur.
Completion of Service Plan
The service plan must be signed by the provider representative.
•
•
For an ALF, the provider must be the facility administrator or a person designated in writing by the
administrator.
For an AFCH, the provider who is the licensee or the designated relief person in the absence of
the provider must sign the service plan.
The service plan must be signed by the resident except:
•
•
If the resident has a legal guardian, the guardian must sign the form on the resident's behalf.
If the resident has a representative or designee established pursuant to Section 400.402, Florida
Statutes, that person may sign the form on the resident's behalf.
The service plan is considered complete as of the last date signed by either party.
Time Frames
For a new resident, the service plan must be completed no more than 15 days after admission (or the date
of the health assessment if after admission).
A new service plan must be completed annually, which means no more than 15 days after the annual
health assessment.
A new service plan must be completed no more than 15 days after a health assessment is performed due
to a significant change in the condition of the resident.
Significant Change
A sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight
change, stroke, heart condition, or stage 2, 3, or 4 pressure sore. Ordinary day-to-day fluctuations in
functioning and behavior, a short-term illness such as a cold, or the gradual deterioration in the ability to
carry out the activities of daily living that accompanies the aging process are not considered significant
changes.
--Rule 58A-5.0131, Florida Administrative Code
July 2001
D-4
PART I
APPENDIX E
RESIDENT SERVICE LOG
The following page contains an optional resident service log for assistive care services. The
form may be copied and used by providers to document the resident service log.
INSTRUCTIONS
Set Up the Form
• Fill in the name of the provider and the month and year.
• Fill in the names and Medicaid numbers of current residents.
• If there are less than 31 days in the month, cross out extra days.
How to Code Your Census
Each day, code who was or was not in the facility on the previous day. For example: On the
second day of the month, enter "Y" for residents who were in the facility and "N" for residents
who were not in the facility on the first day of the month.
As new residents are admitted during the month, add them to the form and code as appropriate.
Admission and Discharge
You can bill Medicaid for the day the person is admitted to the facility, but you cannot bill
Medicaid for the day the person is discharged from the facility.
• Code the day the person was admitted as "Y."
• Code the day the person was discharged as "N."
Temporary Absences
You cannot bill Medicaid for temporary absences of more than 24 hours. Such absences might
be for hospitalization, home visits, etc.
• Code the day the person left the facility as "N."
• Code the day the person returned to the facility as "Y."
Completing the Form
At the end of the month, total the number of days (Y) each resident was in the facility and enter
in the Days column at the right.
Total the number of residents in the facility each day at the bottom.
Add both sets of figures--you should have the same total each way.
July 2001
E-1
(Optional Form for Medicaid Assistive Care Services)
FACILITY NAME ____________________________________________
Resident Name
Medicaid #
1
TOTALS
(AHCA Form 5000-3100A July 2001)
2
3
4
5
6
7
8
9
10
11
12
13
MONTH & YEAR _____________________________________
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Days
(Optional Form for Medicaid Assistive Care Services)
FACILITY NAME _____Stars ALF______________________________
Resident
Name
Gibson, Mel
Midler, Bette
Cruise, Tom
Roberts, Julia
Newman, Paul
Grier, Pam
Pitt, Brad
Streep, Meryl
Smith, Will
Ryan, Meg
Medicaid #
000
000
000
000
000
000
000
000
000
000
TOTALS
MONTH & YEAR _____February 2000___________________
T
1
F
2
S
3
S
4
M
5
T
6
W
7
T
8
F
9
S
10
S
11
M
12
T
13
W
14
T
15
F
16
S
17
S
18
M
19
T
20
W
21
T
22
F
23
S
24
S
25
M
26
T
27
W
28
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
9
9
8
8
9
9
8
8
9
10
9
10
10
10
10
10
10
10
9
10
9
9
9
8
8
9
9
(AHCA Form 500-3100A July 2001)
29
30
31
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
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x
x
x
x
x
x
x
24
28
28
26
20
28
25
28
28
23
9
0
0
0
253
Days
RESIDENT SERVICE PLAN FOR ASSISTIVE CARE SERVICES
(Optional Form)
FACILITY:
DATE:
RESIDENT NAME:
MEDICAID #:
Beginning Date of Service Plan ____________________
Ending Date of Service Plan_________________
ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLs)
ACTIVITY
SERVICE NEED
AMBULATION
o Independent
o Provide Assistance
o Assist with Ambulatory Device
o Wheelchair o Walker o Cane
PROVIDER
o Facility Staff
Other ________________________
Expected Outcome of Service: _____________________________________________________________________
Comments: _____________________________________________________________________________________
BATHING
o Independent
o Provide Supervision
o Provide Total Help
o Tub
o Shower
o Morning
o Evening
o Facility Staff
Other _______________________
Comments: _____________________________________________________________________________________
DRESSING
Choose
attire
o
o
o
o
Put on
shoes
o
o
o
o
Dress/
Undress
o
o
o
o
o Facility Staff
Independent
Provide Supervision
Provide Assistance
ProvideTotal Help
Other _______________________
Comments: _____________________________________________________________________________________
TOILETING
o Independent
o Supervision/Prompting
o Incontinent:
o Bladder o Bowel
o Adult Brief
o Catheter Care
o Ostomy
Assistance
o Facility Staff
Other _______________________
Expected Outcome of Service: _______________________________________________________________________
Comments: _______________________________________________________________________________________
EATING
Special diet:
o Independent
o Hand Guidance
o Cutting Food
o Opening Packages
o Facility Staff
Other _______________________
o Regular o Diabetic o No added salt o Low fat/Low cholesterol Other _________________
Expected Outcome: _______________________________________________________________________________
Comments: ______________________________________________________________________________________
AHCA FORM 2900 (July 2001)
Page 1 of 3
GROOMING
o Independent
o Teeth
o Hair
o Nails
Other____________
o Facility Staff
Other _______________________
Comments: _____________________________________________________________________________________
TRANSFERRING
o Independent
o Facility Staff
Other _______________________
Comments: _____________________________________________________________________________________
ASSISTANCE WITH SELF-ADMINISTERED MEDICATION
ACTIVITY
MEDICATIONS
SERVICE NEED
o Independent
o Provide Daily Supervision or Assistance
o Provide Administration
PROVIDER
o Facility Non-Nursing Staff
o Facility Nursing Staff
Other ________________________
Comments: _____________________________________________________________________________________
ASSISTANCE WITH INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
ACTIVITY
MAKING A
TELEPHONE
CALL
SERVICE NEED
o Independent
o Supervision/ Prompting
o Dial Number
PROVIDER
o Facility Staff
Other ___________________
Comments: ____________________________________________________________________________________
MANAGING
MONEY
o Independent
o Representative Payee or Power of Attorney
o Facility Staff
Other ___________________
Comments: _____________________________________________________________________________________
SHOPPING FOR
PERSONAL ITEMS
o Independent
o Facility Staff
Other ___________________
Comments: _____________________________________________________________________________________
Page 2 of 3
USING AVAILABLE
TRANSPORTATION
o Independent
o Provide Assistance or Escort
o Facility Staff
Other ___________________
Comments: _____________________________________________________________________________________
HEALTH SUPPORT
ACTIVITY
REMINDING
RESIDENT OF
IMPORTANT TASKS
SERVICE NEED
PROVIDER
o Independent
o Appointments
o Daily Tasks
o Other ____________________________
o Facility Staff
Other ___________________
Comments: _____________________________________________________________________________________
OBSERVING RESIDENT’S
APPEARANCE AND WELL-BEING
o Weekly or Less
o Daily
o Other ____________________
o Facility Staff
Other ___________________
Comments: _____________________________________________________________________________________
OTHER SERVICES
ACTIVITY
SERVICE NEED
PROVIDER
Comments: _____________________________________________________________________________________
Comments: _____________________________________________________________________________________
CONSUMER COMMENTS:
Facility Administrator or Designee
DATE
Resident or Representative
DATE
Page 3 of 3
PART II
CHAPTER 4
PURPOSE, BACKGROUND, AND PROGRAM SPECIFIC INFORMATION
Overview
Introduction
This chapter describes Florida Medicaid’s Assisted Living for the Elderly
(ALE) waiver services program, specifies the authority regulating ALE
waiver services, the purpose of the program, and provider qualifications and
responsibilities.
Legal Authority
Medicaid waiver programs, also called home and community-based services
(HCBS), are authorized under Section 1915(c) of the Social Security Act
and governed by Title 42, Code of Federal Regulations (C.F.R.), Part
441.300.
The Florida Medicaid ALE waiver is authorized by Chapter 409, Florida
Statutes (F.S.) and the Florida Administrative Code (F.A.C.), Chapter 59G8.200.
In This Chapter
TOPIC
PAGE
4-1
4-2
ALE Waiver
Description
July 2001
The ALE waiver is a Medicaid program that provides extra support and
supervision through provision of home and community based services to
eligible recipients living in assisted living facilities (ALFs) licensed for
extended congregate care (ECC) or limited nursing services (LNS).
4-1
Description and Purpose, continued
ALE Waiver
Description,
continued
ALE waiver recipients must demonstrate functional deterioration that would
result in placement in a nursing facility were it not for the provision of ALE
waiver services.
Purpose
The purpose of the ALE waiver program is to promote, maintain, and
restore the health of eligible recipients, and to minimize the effects of illness
and disability in order to delay or prevent institutionalization.
The program provides assisted living services, incontinent supplies, and case
management services to eligible recipients living in ALFs, to enable them to
live in the home-like setting of an ALF as long as possible.
Medicaid
Reimbursement
This portion of the handbook is intended for use by ALFs and case
management agencies that provide ALE waiver services to eligible recipients
in assisted living facilities. It must be used in conjunction with the Medicaid
Provider Reimbursement Handbook, Non-Institutional 081, which
contains information about the Medicaid program in general, as well as
specific procedures for submitting claims for payment.
Introduction
The ALE waiver program is jointly administered by the Agency for Health
Care Administration (AHCA), the Department of Elder Affairs (DOEA) and
the Department of Children and Families (DCF).
•
July 2001
AHCA is responsible for assuring compliance with federal program
requirements, developing Medicaid policy, and for reimbursing Medicaid
providers.
4-2
Introduction,
continued
•
•
Area Agency on
Aging and Medicaid
Waiver Specialist
DOEA is responsible for the operational administration of the program
and determining level of care (LOC).
DCF is responsible for determining the recipient’s financial eligibility.
An Area Agency on Aging (AAA) is located in each DOEA-designated
planning and services area (PSA).
The AAA employs a Medicaid waiver specialist who is responsible for:
• Receiving waiver enrollment packets from ALFs and case management
agencies;
• Verifying with AHCA that ALF providers meet licensure requirements
and ensuring case management agencies meet waiver standards;
• Facilitating enrollment of eligible providers with the Medicaid fiscal agent;
• Training providers and furnishing technical assistance;
• Monitoring recipient case records through on-site reviews conducted in
provider facilities;
• Preparing written monitoring reports for the provider, DOEA, and
AHCA;
• Managing the PSA-wide general revenue budget spending authority; and
• Coordinating with Area Medicaid offices, DCF, and the Medicaid fiscal
agent, as needed.
Note: To obtain a list of AAA addresses and telephone numbers, contact
DOEA Medicaid Waiver Programs by telephone at: (850) 4142000; 994- 2000 (Suncom); on the Elder Affairs Web Site,
http://elderaffairs.state.fl.us; or by mail at 4040 Esplanade Way,
Suite -315, Tallahassee, Florida 32399-7000.
July 2001
4-3
ALE Waiver Facility
Provider
Qualifications
Facility Provider
Responsibilities
Medicaid ALE waiver providers must:
• Be enrolled with the Medicaid fiscal agent as an ALE waiver provider;
• Not be currently suspended from Medicare or Medicaid in any state;
•
Be licensed by the Division of Health Quality Assurance (HQA) under
Chapter 400, Part III, F.S., for ECC or LNS; and
•
Specify a staff member to serve as the facility supervisor authorized to
sign service plans, if the administrator does not perform this function.
ALFs are required by licensure to provide sufficient staff and a variety of
services to all individuals residing in assisted living facilities.
The facility staffing for waiver recipients must be based on the amount and
type of services provided to recipients as authorized in plans of care and in
accordance with recipient service needs documented in the consumer
assessment.
ALFs must provide 24-hour on-site staff to meet scheduled or unpredicted
needs and to provide supervision for safety and security.
ALE waiver providers must also:
•
Provide each recipient with a private room or apartment or a semiprivate room or apartment shared with a roommate of the recipient’s
choice and consent;
•
Develop a service plan for each ALE waiver recipient;
•
Specify a staff member to serve as the facility supervisor authorized
to sign service plans, if the administrator does not perform this
function;
•
Comply with all provisions of the Medicaid Provider Agreement;
and
Cooperate with Medicaid monitoring staff or its designated
representatives.
•
July 2001
4-4
Vendor
Qualifications
If an ALF purchases services from a vendor, the vendor and staff must meet
all mandatory educational, licensing, and certification requirements for the
specific area of service furnished.
Referral Agreement
To be reimbursed by Medicaid for ALE waiver services, and prior to the
provision of services, each ALF and case management agency must have on
file with the AAA, a completed, signed and dated Assisted Living Medicaid
Waiver Referral Agreement. Referral agreements are available from the
Medicaid Waiver Specialists in each DOEA Planning and Services Area
(PSA).
Case Management
Case managers begin the assessment process for applicants for entry into the
ALE waiver program and provide ongoing case management oversight of
recipient’s care in ALFs.
There can only be one case manager for an ALE recipient. If a recipient has
a Department of Children and Families placement worker, the ALE case
manager must be designated as the sole case manager when the recipient
becomes an ALE waiver recipient. However, the DCF placement worker
will continue to process Optional State Supplementation (OSS), reviews,
placement, and other associated OSS responsibilities.
July 2001
4-5
Case Management
Agency
Qualifications
Case management ALE waiver providers must be a designated Community
Care for the Elderly lead agency in accordance with Chapter 430, F.S. or
meet the following standards:
•
•
•
July 2001
Employ case management staff with skills, knowledge, education, and
experience to link consumers to community-based services and
resources appropriate to meet their needs;
Have personnel policies which meet or exceed federal, state, DOEA,
AHCA, and AAA and local requirements for licensure, certification, or
other special education and training qualifications for specific personnel
functions;
Have case managers trained and certified on relevant DOEA forms. A
minimum score of 80% on the assessment training is required.
4-6
Case Management
Agency
Qualifications,
continued
•
•
•
•
•
•
•
•
•
•
•
•
•
July 2001
Have case managers who have successfully completed Assisted Living
Facility core training within six months of beginning to serve recipients
under this waiver;
Develop and provide in-service training of at least 4 hours per year for
case managers; training content and length must be documented in staff
records. Training must include due process rights of consumers;
Conduct intake, screening, prioritization, and assessment of individuals in
accordance with the DOEA Intake and Assessment Training Handbook,
(Form 701D);
Maintain 24-hour, 7-day-a-week on-call staff capability for emergency
services referrals including those from DCF and Adult Protective
Services (APS) workers. Assess and initiate services within 72 hours,
or in accordance with local protocols, if determined by the APS to be in
need of immediate services to prevent harm;
Report suspected instances of abuse, neglect, or exploitation of disabled
or elderly persons to the Florida Abuse Hotline;
Have procedures in place for making referrals, accepting referrals, and
serving referrals from other agencies;
Initiate and maintain coordination among agencies providing service and
referrals to consumer within the community;
Establish and maintain communications and coordination with other
agencies serving clients in common;
Complete and maintain case records in accordance with the DOEA care
plan handbook;
Have the staff and capability to collect, analyze, and transmit consumer
demographic and service data electronically;
Have administrative and supervisory staff available on-site to provide
oversight and direction to case management staff, ensure compliance
with accounting and financial requirements, and develop and implement
quality assurance measures including cost effectiveness;
Have adequate procedures in place to avoid any potential for conflict of
interest between the role of case management and service provision;
Have a process to monitor quality provision of service providers;
4-7
Case Management
Agency
Qualifications,
continued
•
•
•
•
•
Case Manager
Qualifications
Maintain caseloads no greater than 60 individuals;
Observe confidentiality requirements;
Have procedures in place which assure applicants and consumers are
educated of their right to file a grievance and afforded all due process
rights;
Prepare and update as needed a disaster preparedness plan which
includes training and coordination with the local emergency management
office; and
Maintain financial capability including having a minimum of a 60 day
operating reserve in the form of cash or current credits.
An ALE waiver case manager must have a bachelor’s degree in social work,
sociology, psychology, or a related social services field and have one year of
related professional experience. If the bachelor’s degree is not in a social
services field, two years of related professional experience is required.
Professional human services experience may substitute on a year for year
basis for the educational requirement.
An ALE case manager must be an employee of an enrolled case
management agency and successfully complete assisted living core training
within the first six months of employment.
July 2001
4-8
Case Manager
Responsibilities
The case manager is responsible to:
•
•
•
•
•
•
•
•
•
•
Medicaid Fraud and
Abuse
July 2001
Assist ALE applicants with making application for Medicaid waiver
services;
Advise the ALE applicant and recipient of their fair hearing rights and the
grievance process;
Develop and implement an assessment-based plan of care for each
recipient;
Review plans of care every three months to assure the continued need
for waiver services;
Visit each recipient at least once every 30 days and document the
recipient’s status, satisfaction with services and additional service needs
in the recipient’s case record;
Maintain up-to-date recipient case records;
Coordinate other services provided to the consumer, including hospice
and Medicare with the ALE service provider for waiver recipients
electing to receive those services;
Contact the service provider when there is indication that needed
services are not being rendered in order to have those services reinstated
immediately;
Contact the Agency for Health Care Administration, Health Quality
Assurance (MC/HQA) simultaneously with the Medicaid waiver
specialist within 24 hours of a site visit if a recipient is not receiving
needed services; and
Notify the Florida Abuse Hotline immediately in cases where lack of
service provision endangers the recipient’s health, safety, or welfare.
See Chapter 5 of the Medicaid Provider Reimbursement Handbook,
Non-Institutional 081, for information regarding Medicaid policy on
provider abuse and fraud and Medicaid’s recoupment policies.
4-9
PART II
CHAPTER 5
COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS
Overview
Introduction
This chapter describes the services covered under the Florida Medicaid
Assisted Living for the Elderly (ALE) waiver. It also describes the
requirements for service provision, service limitations, and exclusions.
In This Chapter
TOPIC
PAGE
Requirements To Receive Services
5-1
Case Management Requirements
5-4
Case Management Documentation
5-5
Plan of Care
5-6
Plan of Care Review and Reassessment
5-9
ALE Waiver and Assistive Care Covered Services
5-9
Placement and Discharge
5-17
5-18
Requirements to Receive Services
Introduction
July 2001
Medicaid can reimburse for services provided in assisted living facilities
(ALFs) to eligible Medicaid recipients who are enrolled in the ALE waiver
program.
5-1
Medicaid
Application
Responsibilities
Individuals who have not applied for and been determined eligible for
Medicaid at the time they need ALE services must complete or have a
designated representative complete and submit a Request For Assistance
(RFA) to the local Department of Children and Families (DCF), Office of
Economic Self-Sufficiency.
Prior to determining eligibility, DCF will require verification that the individual
is a resident of an enrolled ALF, is receiving case management, has a level of
care, and has been determined to need ALE services in order to remain in the
ALF or in order to move into an ALF.
Who Can Receive
Services
To receive ALE waiver services, recipients in this waiver must be 60 years of
age or older and meet the following requirements:
•
•
•
•
•
•
Functional Criteria
Functional criteria include limitations in activities of daily living (ADLs).
ADLs are defined as bathing, dressing, grooming, ambulating, eating, toileting,
and transferring. To qualify for ALE waiver assistance, the recipient must
need an average of more than one hour of direct services per day and meet at
least one of the following criteria:
•
•
July 2001
Medicaid eligible;
Determined disabled according to Social Security standards if under 65
years of age;
Deemed appropriate for ALF placement by the facility administrator;
Moving out of a nursing facility or other institutional program, be an ALF
resident needing additional services in order to remain in the ALF, or be
living at home and determined at risk of nursing facility placement and
desiring to move into an ALF;
Have a case manager employed by a waiver enrolled case management
agency; and
Meet one or more functional criteria.
Require assistance with four or more ADLs or three ADLs plus
supervision or administration of medication;
Require total help with one or more ADLs;
5-2
Functional Criteria,
continued
•
•
•
Level Of Care
Have a diagnosis of Alzheimer’s disease or another type of dementia and
require assistance with two or more ADLs;
Have a diagnosed degenerative or chronic medical condition requiring
nursing services that cannot be provided in a standard ALF but are
available in an ALF licensed for limited nursing or extended congregate
care; or
Be a Medicaid-eligible recipient who meets ALF criteria, awaiting
discharge from a nursing facility placement and who cannot return to a
private residence because of a need for supervision, personal care,
periodic nursing services, or a combination of the three.
Level of care (LOC) determinations are made by the Department of Elder
Affairs (DOEA) Comprehensive Assessment and Review for Long Term
Care Services (CARES) unit. The level of care verifies that the recipient is at
risk of institutionalization and gives the level of care the recipient would
require upon institutional placement.
An ALE waiver recipient must meet an Institutional Care Program (ICP)
LOC requirement that is verified on a DOEA-CARES Form 603,
Notification of Level of Care, which is completed by CARES.
The LOC must be reviewed annually for all recipients and documented in the
recipient’s case record. Case managers are required to track LOC
reassessments to ensure that timely evaluations are conducted and should
notify CARES whenever an overdue LOC reassessment is detected.
Any applicant or consumer who is determined not to meet a level of care will
be notified through the DCF Office of Economic Self-Sufficiency and notified
of their right to request a fair hearing.
Note: See Part II, Chapter 6, Appendix G of this handbook for fair hearing
July 2001
5-3
Case Management Requirements
Description
Every ALE waiver recipient must have a case manager who is employed by
a waiver enrolled case management agency.
Case management includes identifying, organizing, coordinating, and
monitoring services needed by a recipient. The case manager assists waiver
recipients in gaining access to waiver services as well as other services,
regardless of the funding source.
Note: See Chapter 4, Case Manager Responsibilities for more information
regarding the responsibilities of case managers.
Components
July 2001
Case management must include the following documented activities:
• Comprehensive needs assessment and identification of appropriate
service needs;
• Development of plans of care and authorization of services and service
components;
• Referral to available resources;
• Coordination of hospice and waiver services when the ALE consumer
elects hospice care;
• Coordination of Medicare services with ALE waiver services;
• Monitoring of services rendered;
• Reassessment of recipient needs; and
• Review of fair hearing rights.
5-4
Case Management Documentation
Case Records
A case record must be kept by the case manager for every recipient
receiving ALE waiver services. The purpose of keeping this record is to
assure that information regarding the recipient’s condition and service
provision is contained and available for review at a single location. It is the
basis of the recipient’s plan of care and the basis for quality assurance
monitoring.
The case manager is responsible for developing and maintaining the case
record. The case manager must record all case management activities in the
case narrative including:
•
•
•
•
•
Copies of all eligibility documents;
Assessments;
Plans of care, including accurate cost projections;
Case narratives; and
Affirmation of receipt of fair hearing rights.
Case records are maintained by the case management agency at a central
location.
Handbook, Non-Institutional 081, for additional information about
documentation requirements.
Case Narrative
Requirements
All case management activities must be recorded in the case narrative.
• The narrative must be clear and comprehensive, reflecting what the case
manager has done to meet the needs identified in the plan of care.
• There should be documentation of any information that the case manager
has learned about the activities of others on behalf of the recipient.
• The case narrative should also contain a record of the case manager’s
observations of the recipient’s status and must be sufficient to justify
payment.
July 2001
5-5
Case Management Documentation, continued
Permanent Record
Documentation
All case record documentation (including the case narrative), must be in ink
and must be legible. No erasures or white out are permitted. Case narrative
entries must be signed and dated by the case manager. In case of an error,
the case manager lines through the error and initials and dates it, then makes
the correct entry.
Computer records
Case narratives may be written on a computer. A printout of the narrative
must be kept in the recipient’s case record. Each computer entry must be
signed and dated by the case manager.
Plan Of Care
Description
A plan of care is a written document that describes the service needs of a
recipient, and specifically identifies the services and service components to
be provided, the provider of services and service components, their
frequency, duration, and estimated cost.
The plan of care is based on a review of assessments by the facility
administration and nursing staff, the DOEA Comprehensive Client
Assessment and the CARES HRS-Med Form 3008, Health Assessment.
The information gathered through these assessments is used by the case
manager to establish the recipient’s plan of care and identifies both waiver
and non-waiver services required to maintain the recipient in the ALF and
reduce functional limitations in order to avoid nursing facility placement.
In order for the ALE provider to bill for ACS, the plan of care must show a
need for ALE waiver services, including an average of more than one hour of
direct services per day. Services must be coordinated and monitored by the
ALE case manager.
July 2001
5-6
Plan Of Care, continued
Purpose
The purpose of the plan of care is to:
•
•
•
•
Comprehensive
Client Assessment
Enable the case manager and the recipient to summarize the findings of
the Comprehensive Client Assessment (Form 701B);
Identify realistic goals for the recipient;
Identify problems that present barriers to attaining the goals; and then,
Develop outcomes and patterns of service delivery that will help resolve
identified problems so that stated goals can be achieved.
The case manager must conduct a comprehensive client assessment, DOEA
Form 701B, by evaluating the recipient's health status, functional status,
support system, and living environment. The case manager must make a
face-to-face visit with the recipient to complete the assessment and may
speak with the recipient’s formal and informal caregivers. The recipient must
give permission for the case manager to contact the caregivers.
The comprehensive client assessment must be placed in the recipient’s case
record as a separately identifiable document. All contacts and visits made in
completing the assessment must be noted in the case narrative.
Plan of Care
Contents
The plan of care must be in writing, based on information obtained during the
comprehensive assessment process and include:
•
•
•
•
•
•
July 2001
Specific services and service components to be provided, with a
beginning date for each;
Who will provide each service and component;
The amount, frequency, and duration of services and components;
Documentation of the dates that services and components are revised or
terminated;
Projected service costs; and
The plan of care review date.
5-7
Plan Of Care, continued
Plan of Care
Contents, continued
All waiver services or service components must be specified in the
recipient’s plan of care. Services or service components not specified in the
plan of care are not considered approved or authorized. Reimbursement for
services furnished, but not specified in the plan of care for that specific time
period, are subject to recoupment.
Assistive Care
Services
Assistive Care Services are described in Part I of this handbook. These
services are not covered services under the ALE waiver, but must be
included in the waiver plan of care. The ACS components are health
support, assistance with activities of daily living, assistance with instrumental
activities of daily living, and medication assistance. ACS service provision is
expected to take an average of about one hour per day. Recipients eligible
for both ACS and ALE waiver assistance must have a service plan in which
services that are considered ACS are shown and identified separately from
those provided under the waiver. The same information should be shown for
each ACS component as for each waiver service.
Approval and
Authorization
The recipient, the recipient’s family or guardian, as appropriate, case
manager and the facility administrator must meet to discuss and agree on the
plan of care.
The plan of care must be signed and dated by the recipient or, the recipient’s
guardian or designated representative when the recipient is not competent to
give his or her consent.
When signing the plan of care, the recipient and the recipient’s family or
guardian are informed that signing the plan of care indicates the recipient
accepts ALE waiver services in lieu of nursing facility placement. The
recipient and the recipient’s family or guardian are also notified in writing of
the right to a fair hearing if services are denied, suspended, reduced, or
terminated. The notice of rights must be sent by certified mail or hand
delivered with a signed acknowledgement of receipt.
The plan of care is considered authorized when it is signed and dated by the
case manager.
July 2001
5-8
Plan of Care Review and Reassessment
Review
The plan of care must be reviewed and updated to reflect the current needs
of the recipient. For the purposes of case review, case managers must
conduct a face-to-face visit at least quarterly, or more frequently depending
on changes in the recipient’s condition. The case manager must monitor the
plan of care for continuity of services and ensure that changes in the
recipient’s status warrant service increases, service reductions, or other
changes in the plan of care. This review is not a complete reassessment.
The case manager must initial and date the plan of care at each review to
certify that authorized services are appropriate and continue to be needed.
Case reviews must be documented in the case narrative.
Reassessment
ALE waiver recipients must receive a quarterly review and updates. A
complete reassessment must be performed annually. Complete
reassessments are conducted by using the comprehensive client assessment
instrument. If changes in the recipient’s condition warrant complete
reassessment, one should be done more frequently than once a year.
Reassessment results will be used to develop a new plan of care.
Reassessments must be maintained in the recipient’s case record and all
contacts and visits made in completing a reassessment must be noted in the
case narrative.
ALE Waiver and Assistive Care Covered Services
Introduction
ALE waiver services are based on individual recipient needs and must be
documented in the plan of care. Recipients enrolled in the ALE waiver must
receive:
• Case management, and
• Assisted living.
The receipt of incontinence supplies is based on need.
July 2001
5-9
ALE Waiver and Assistive Care Covered Services, continued
Assistive Care
Services
Assistive Care Services is a Medicaid state plan service the ALE waiver
providers may provide to their waiver recipients. This is not an ALE waiver
service.
Case
Management
W9655
Case management is a service that provides the ALE waiver recipient with a
case manager who will identify, organize, coordinate, and monitor the
services needed by the recipient. The case manager also assists the recipient
to access needed services.
Assisted Living
W9654
Assisted living is a service that is comprised of an array of components
provided by or through the ALF in which the recipient resides. These
components will be provided only when the recipient is not capable of
performing them and where no relative, caretaker, landlord, community
volunteer or agency, or third party payor is capable or responsible for their
provision.
Each recipient must have a resident contract with the ALF that specifies
services to be provided by the facility. Prior to including a service component
into a recipient’s plan of care, the case manager must examine the recipient’s
resident contract to determine if any needed service component is already
covered by the facility’s basic charges and would be considered duplicative.
Duplicative service components must not be included or authorized in the plan
of care.
The following components may be included in the assisted living service:
• Attendant call system;
• Attendant care;
• Behavior management;
• Chore services;
• Companion services;
• Homemaker services;
• Intermittent nursing;
• Medication administration;
July 2001
5-10
Assisted Living
W9654, continued
•
•
•
•
•
•
Occupational therapy;
Personal care;
Physical therapy;
Specialized medical equipment and supplies;
Speech therapy; and
Therapeutic social and recreational services.
The criteria for provision of each component are explained below.
Attendant Call
System Component
The attendant call system is an emergency response system for recipients
who are at high risk of falling, becoming disoriented or experiencing some
disorder that puts them in physical, mental, or emotional jeopardy requiring
immediate assistance. The recipient either wears an electronic device (e.g., a
medallion or a bracelet) or is in proximity to a button that enables him or her
to summon emergency help from an ALF attendant. This component also
includes alerting the attendant if the recipient wanders from the facility.
Attendant Care
Component
Attendant care is hands-on care, of both a medical and non-medical
supportive nature, specific to the needs of a medically stable, physically
disabled recipient. Supportive services are those that substitute for the
absence, loss, diminution, or impairment of a physical or cognitive function.
Light housekeeping activities that are incidental to the performance of care
may also be furnished as part of this component.
Behavior
Modification
Component
Behavior modification consists of specialized approaches to manage the
behavior of recipients with dementia. These approaches are remedial
measures aimed at preventing or ameliorating disruptive behaviors. They
may include supervision of recipients with behavior problems due to
dementia and educational activities for training caregivers to respond to
recipients’ behavior.
July 2001
5-11
Chore Services
Component
The chore component consists of services needed to maintain the home-like
setting as a clean, sanitary, and safe environment. This component includes
heavy household chores such as washing floors, windows and walls, tacking
down loose rugs and tiles, and moving heavy items of furniture in order to
provide safe access and egress.
Companion Service
Component
The companion service component is provided to functionally impaired
recipients and consists of non-medical care, supervision, and socialization.
Companions may assist the recipient with activities such as meal preparation,
laundry, and shopping, but do not perform these activities as discrete
services. The provision of companion service does not entail hands-on
medical care. Companions may perform light housekeeping tasks incidental
to the care and supervision of the recipient.
This component is provided in accordance with a therapeutic goal in the plan
of care and is not intended to be diversional.
Homemaker
Component
The homemaker component consists of general household activities (meal
preparation and routine household care) provided by a trained homemaker.
Intermittent Nursing
Component
Intermittent nursing consists of services provided by a licensed nurse on an
as-needed basis to ensure therapeutic regimens such as changing dressings,
administering medications, assessing the recipient’s state of health, and other
activities within the scope of the nursing practice.
Medicaid does not reimburse for continuous nursing services provided to
ALE waiver recipients.
July 2001
5-12
Medication
Administration
Component
Medication administration, supervision and assistance may be provided to
ALE waiver recipients as long as qualified staff is available to render the
service component.
Medication supervision and administration can only be provided by licensed
nurses. Assistance with self-administered medications can be provided
either by a licensed nurse or, with a documented request and informed
consent, an unlicensed staff member. The unlicensed staff member must be
trained to assist residents with self-administered medications, in accordance
with Chapter 58A-5.0191(5), F.A.C., and must demonstrate the ability to
accurately read and interpret a prescription label. Pursuant to 400.4256,
F.S., assistance with self-administration of medications includes taking the
medication from where it is stored and delivering to the resident; removing a
prescribed amount of medication from the container and placing it in the
resident’s hand or another container; helping the resident by lifting the
container to his or her mouth; applying topical medications; and keeping a
record of when a resident receives assistance with self-administration of his
or her medications.
Occupational
Therapy
Component
Occupational therapy assists with the functional needs of recipients related to
the performance of self-help skills, adaptive behavior and sensory, motor
and postural development. Occupational therapy will be provided by
licensed occupational therapists, occupational therapy assistants, or
occupational therapy aides under the supervision and direction of a licensed
occupational therapist.
Personal Care
Component
The personal care component provides assistance with eating, bathing,
dressing, personal hygiene, and other activities of daily living. This
component may provide assistance with the preparation of meals and other
housekeeping activities essential to the health and welfare of the recipient.
July 2001
5-13
Physical Therapy
Component
The physical therapy component is directed toward the development,
improvement, or restoration of neuromuscular or sensory motor function,
relief of pain, or control of postural deviation to attain maximum
performance. Physical therapy must be provided by licensed physical
therapists, physical therapy assistants, or physical therapy aides under the
supervision and direction of a licensed physical therapist.
Specialized Medical
Equipment and
Supplies
Component
The specialized medical equipment and supplies component includes devices,
controls, or appliances that are of direct medical or remedial benefit to the
recipient. Such items must be specified in the plan of care and enable a
recipient to increase his or her ability to perform activities of daily living, or to
perceive, control, or communicate with the environment in which he or she
lives.
This component must include consultation with the recipient’s physician and
denials from all other payment sources.
Speech Therapy
Component
Speech therapy is provided when medical diagnosis indicates a need for
treatment of speech and language disorders that result in a communication
disability. This component is limited to the evaluation and treatment of
speech disorders, such as aphasia, which result from stroke and cerebral
trauma, dementia, or other degenerative neurologic diseases affecting oral
motor functions. Speech therapy services must be provided by licensed
speech-language pathologists or a certified speech-language pathology
assistant under the supervision of a licensed speech-language pathologist.
Therapeutic Social
and Recreational
Services
Component
The therapeutic social and recreational services component allows the ALF
to provide activities to improve the mobility, motor skills, or alertness of ALE
waiver recipients. These activities may also serve to divert the attention and
enhance the quality of life of waiver recipients with dementia.
July 2001
5-14
Assistive Care
Service
Components (This is
a Medicaid state
Plan service)
The following components can be provided under the assistive care service
plan:
•
Health support;
•
•
•
Each of the service components is described below.
Health Support
Component
Health support is defined as requiring the provider to:
• Observe the recipient’s whereabouts and well-being on a daily basis;
• Remind the recipient of any important tasks on a daily basis; and
• Record and report any significant changes in the recipient’s appearance,
behavior, or state of health to the recipient’s health care provider,
designated representative, or case manager.
Assistance with
Activities of Daily
Living (ADLs)
Component
Assistance with activities of daily living (ADLs) is defined as providing
assistance with one or more of the following activities: individual assistance
with ambulating, transferring, bathing, dressing, eating, grooming, and
toileting. At least one service must be required daily.
Assistance with
Instrumental Acts of
Daily Living
(IADLs)
Component
Assistance with instrumental activities of daily living (IADLs) is defined as
providing intensive assistance with one or more of the following activities:
individual assistance with shopping for personal items, making telephone
calls, and managing money.
Assistance with
Self-Administration
of Medication
Component
Assistance with self-administration of medication is defined assistance with or
supervision of self-administration of medication at least daily in accordance
with licensure requirements applicable to the facility type.
July 2001
5-15
Incontinence
Supplies
W9656
Incontinence supplies are items essential to enabling health care personnel to
carry out diagnostic and therapeutic care including ostomy or colostomy
supplies, irrigation solutions, bedpans, adult diapers, bed pads and supplies
necessary to maintain healthy skin. Such items must be specified in an
approved plan of care.
Assistive Care
Services
W9657 (This is a
Medicaid state
plan service.)
Assistive care services are an array of services provided on a daily basis by
or through ALE participating ALFs.
The following components may be included in the assistive care service plan:
•
Health support;
•
•
•
The criteria for provision of each component are explained in a preceding
section.
Services
Documentation
The following specific elements must be documented for all ALE waiver
services or service components rendered to waiver recipients:
• Name of provider, provider agency, and specific individual rendering
each service;
• Type of service or service component provided;
• Amount of service provided;
• Date of service; and
• Place of service.
Case management documentation must clearly describe the activities
associated with maintaining the recipient in the ALE setting. The
documentation should show that services are consistent with the plan of care
and are being delivered according to the plan.
July 2001
5-16
Permanent Record
Documentation
All documentation must be in ink and must be legible. When computer
records are used, a copy of the computer records are required to be printed,
signed, dated, and maintained in the client file. No erasures or white out are
permitted. All entries must be signed and dated. In case of an error, the
provider must line through the error, initial and date it, then make the correct
entry.
Placement and Discharge
Introduction
Residency in an ALE enrolled ALF is a requirement of eligibility for receipt of
ALE services. If a recipient has met all the criteria for receipt of ALE services
except placement into an ALE enrolled ALF or is in one ALF and will be
moving to another, according to the circumstances, denial of waiver services
or termination from the ALE waiver may be necessary. Any time this occurs,
the affected recipient will be advised of his or her appeal rights.
Note: See Part II, Chapter 6, Appendix G of this handbook for fair hearing
Nursing Facility
Placement
If a recipient who is receiving ALE services becomes too debilitated to
remain in the ALF, the ALF in coordination with the case manager will
contact CARES for an assessment and recommendation for appropriate
nursing facility placement.
Any time a nursing facility placement is necessary for an ALE waiver recipient
who receives Optional State Supplementation (OSS) payments, the
placement must be coordinated with DCF.
July 2001
5-17
Placement and Discharge, continued
Move To Another
ALF
If a recipient requests to move or is moved:
•
•
From one ALE-enrolled facility to another ALE-enrolled facility, the case
manager will assist in coordinating the placement and the recipient will
remain eligible to receive ALE services in the new ALF; or
From one ALE-enrolled ALF to an ALF that is not an ALE-enrolled
waiver provider, the case manager will terminate the recipient from the
ALE waiver and services will be discontinued.
Any time a change in facilities is necessary for a recipient who receives
Optional State Supplementation (OSS) payments, the change must be
coordinated with DCF.
ALF Discharge
Requirements
If an ALF administrator initiates discharge of an ALE recipient from the ALF,
the discharge must be done in accordance with the facility’s written policies
and the recipient or recipient’s designated representative or guardian must be
given appropriate notice in accordance with Chapter 58A-5, F.A.C.
Introduction
July 2001
Recipients may be terminated from the ALE waiver. Case managers
determine when to terminate a recipient from ALE services. Upon
termination, the case manager must immediately cancel all waiver services
being provided to the recipient. The case manager must also notify the
recipient or the recipient’s designated representative or guardian, the ALF,
the local DCF office, and the ALE waiver specialist of the recipient’s waiver
termination. ALE recipients must be given a written 10-day advance notice of
termination including their right to request a fair hearing.
5-18
Termination of Services, continued
Reasons For
Termination
A recipient who is terminated from ALE services for any one of the following
reasons must be given a fair hearing notice:
• Loss of Medicaid eligibility;
• The recipient’s physical condition no longer meets functional criteria;
• The recipient moved to a non-waiver setting;
• The recipient was placed in a nursing facility;
• The recipient elected to stop ALE services;
• The recipient refused to comply with the plan of care; and,
• The recipient would not accept treatment from any of the available
enrolled providers.
DOEA Grievance
Procedure
ALE waiver consumers can file a grievance with DOEA concerning any
action taken by DOEA or the DOEA service provider network. Consumers
should contact their case managers for assistance with their grievance. Case
managers must assist the consumer or the designated representative with
preparation and presentation of the grievance. Participation in the DOEA
grievance process does not affect a consumer’s right to a fair hearing.
Right To A Fair
Hearing
An ALE consumer has the right to appeal any action taken by the ALF,
AHCA, DOEA or DCF that adversely affects the recipient’s receipt of
services.
Note: See Part II, Appendix G for details on how to access the fair hearing
process.
July 2001
5-19
PART II
CHAPTER 6
PROCEDURE CODES AND FEES
Overview
Introduction
This chapter provides and describes the procedure codes and approved fees
for assisted living for the elderly (ALE) waiver services.
In this Chapter
TOPIC
PAGE
6-1
Appendix F: Procedure Code Table and Fees
F-1
Appendix G: Appeal Rights and Fair Hearing Process
G-1
Introduction
Medicaid reimburses for home and community based waiver procedure codes
based on the Centers for Medicare and Medicaid Services (CMS) Common
Procedure Coding System (HCPCS), Level III procedure codes and locally
assigned codes that have been approved by HCFA. Locally assigned codes
are identified by a “W” prefix.
Medicaid
Reimbursement
Claim Form
ALE waiver services are billed on the Non-Institutional 081 claim form.
July 2001
Note: See the Medicaid Provider Reimbursement Handbook, NonInstitutional 081, for specific procedures for submitting claims for payment.
6-1
Procedure Code
Table
Case Management
Reimbursement
ALE waiver providers may bill for three waiver services and one state plan
service provided in their facilities. The procedure code for each service is
found in Appendix F of this chapter. Each service and its components have
been explained in Chapter 5 of this handbook. The table gives:
•
The procedure code associated with the service;
•
The name of the service; and
•
The maximum fee that Medicaid will reimburse for the service.
Case management activities are paid on a fixed monthly rate. Reimbursement
will be made if case management activities were provided for a recipient for any
portion of the month. Any of the following activities constitute case
management:
•
•
•
•
•
•
•
July 2001
Assisting with a recipient’s facility placement or enrollment into the ALE
waiver;
Conducting an assessment or reassessment of service needs;
Developing or reviewing a care plan, including arrangements for service
delivery and referral activities;
Conducting a monitoring visit for provision of services or to assess the
quality of services being rendered;
Advocacy or legal related tasks such as working with adult protective
services, court officials or other investigators on behalf of an eligible
recipient;
Time spent recording activities in the recipient’s case record, telephone
time or travel time associated with any of the above case management
activities; and
Coordinating hospice, Medicaid state plan and Medicare services with the
hospice coordinator for ALE consumers electing to receive those services.
6-2
Billing for Case
Management
ALE case management services are billed once a month. The date of service
(DOS) is always the last day of the month for which reimbursement is
requested. However, if the recipient is admitted to a hospital or a nursing
facility, the DOS must be the day before the recipient’s admission in order for
case management to be reimbursed.
Incontinence
Supplies Service
This service is billed once a month using the last day of the month for which
reimbursement is being requested. The total billing should represent the value
of those incontinence supplies used by the waiver consumer. Individual waiver
consumer supplies must be maintained in separate locations and ALE providers
must keep accurate monthly records of supplies used by individual waiver
consumers. However, if the recipient is admitted to a hospital or a nursing
facility, the date of service (DOS) must be the day before the recipient’s
admission in order for incontinence supplies to be reimbursed.
Assisted Living
Service Component
Reimbursement
The assisted living service components are reimbursed at a single per diem rate.
Billing for Assisted
Living Service and
ACS Components
Assisted living service components and assistive care service components are
reimbursed by the number of days (i.e., units) the recipient resides in the facility
while enrolled in the ALE waiver. The total number of units is billed once a
month using the last day of the month for which reimbursement is requested as
the date of service (DOS). The billing method should be consistent, preferably
once per month. However, if the recipient is admitted to a hospital or a nursing
facility, the last DOS must be the day before the recipient’s admission.
July 2001
Reimbursement will not be made for any continuous 24-hour period that the
recipient is temporarily absent from the facility.
6-3
Billing for ACS and
Assisted Living
Waiver Services
Facilities participating in the ALE Waiver are required to bill Medicaid for both
the ACS state plan service and the ALE waiver services for some recipients.
Waiver Daily Rate Calculation Worksheet
Instructions for Worksheet
1. Insert the number of days in the month on Line A
2. Calculate the Maximum Waiver and ACS for the Month
(Lines C and D)
3. Perform the calculations from Line F through Line L to obtain
the daily waiver payment (L) to bill for the days the recipient received
services in the facility.
4. If Line I is “0” (Zero), do not bill for ACS.
A.
B.
C.
D.
E.
Number of Days in the Month
Maximum Daily Waiver Rate
Maximum Waiver for the Month: A times B
Assistive Care Service Daily Rate
ACS for the Month: A times D
F.
Is Resident Income Greater than $716.00 and less than
$770.00?
If YES, add C plus G and Subtract $54.00
IF NO, add C plus $716.00
G.
Method I
Recipient Income: Insert Income
Social Security:
_________
OSS (State Subsidy): _________
Other (Income, if any)_________
Total Income:
__________
H
I.
Subtract G from F
Is recipient Income (G) more than $716.00?
If Yes, Insert “0” (Zero).
If No, Insert ACS for the month (E)
Subtract I from H
Add J plus $54.00
Daily Waiver Rate: Divide K by A
J.
K
L.
July 2001
$28.00
$9.28
Method II
(From Notice of Case Action)
Needs Allowance: ________
Pat. Resp.:
________
Total Income
_________
6-4
Billing for ACS and
Waiver Services,
continued
ALE waiver recipients with incomes up to $716.00 per month are eligible for
ACS and ALE waiver payments.
The ALE waiver facility reimbursement under the waiver program is $1,500.00
for a 28 day month, $1,556.00 for a 30 day month, and $1,584.00 for a 31
day month.
Daily Billing for
Assisted Living
Waiver and State
Plan Service
Components
ALE waiver recipients must be present in the ALF for some period each day
that is billed for assisted living services. However, no billing is permitted for
partial days of service.
When the ALE resident is transferring between two ALE assisted living
facilities, the discharging facility may not bill for the day of discharge and the
admitting facility may bill for the day of admission.
When the ALE recipient is transferring to either a hospital or nursing home, the
ALE facility cannot bill for the date of discharge.
When the ALE resident is returning from a hospital, nursing home stay, or other
temporary absence, the ALE facility can bill for the date of return.
Recipient
Responsibility
As part of the eligibility process, DCF applies a standard formula to calculate a
financial responsibility, if any, for recipients who receive ALE waiver services.
The ALF, recipient, and the case manager are notified by DCF using a Notice
of Case Action form of the recipient’s financial responsibility. This monthly
amount must be deducted from the total charges for assisted living services
prior to submitting a claim for reimbursement to Medicaid.
The ALF is responsible for collecting the financial responsibility from the
recipient and may establish individual collection methodologies to fit the
circumstances of each recipient.
July 2001
6-5
PART II
APPENDIX F
PROCEDURE CODE TABLE AND FEES
CODE
DESCRIPTION OF SERVICE
G9012 U3
Case Management
T1020 U3 TS
Assisted Living
S5199 U3
Incontinence Supplies
UNIT
PER DIEM RATE
Monthly
$100
Daily
$28
Monthly
$125
Note: ALE waiver providers can bill for ACS state plan services using procedure code
T1020 U3 for residents with incomes up to $716.00 per month. The daily reimbursement
rate for ACS is $9.28. This procedure code can only be used by ALE waiver providers
billing on the 081 billing form.
October 2003
F-1
PART II
APPENDIX G
APPEAL RIGHTS AND FAIR HEARING PROCESS
Fair Hearing Process
Right to a Fair
Hearing
A recipient or applicant has the right to appeal any action taken by the Agency
for Health Care Administration (AHCA), Department of Elder Affairs (DOEA),
Department of Children and Families (DCF) or service providers that adversely
affects the recipient’s receipt of services.
ALE recipients must be given at least 10 calendar days advance written notice of
any suspension, reduction, or termination of services or program participation.
The advance notice must inform the ALE recipient of the right to a fair hearing.
Where to Apply for
a Hearing
Hearing requests must be sent to the DCF, Office of Hearing Appeals (OSIH),
1317 Winewood Boulevard, Building 5, Room 203, Tallahassee, Florida
32399-0700. The telephone number is (850) 488-1429.
How to Request a
Hearing
The ALE waiver applicant, recipient, or authorized representative must request a
hearing within 90 days of the receipt of the written notification of the adverse
decision. ALE case managers must offer assistance to recipients or applicants
with the fair hearing process.
Continuation of
Benefits
If the ALE applicant, recipient, or authorized representative requests a fair
hearing within 10 calendar days of the receipt of the notice of case action or
denial of service, waiver services must be reinstated at the level prior to the
adverse action.
If an ALE applicant or recipient requests a fair hearing and services are
reinstated to the prior level, the recipient might be requested to repay that
portion of the benefits that the hearing decision determines to be invalid. The
recipient must be given written notice of this responsibility.
July 2001
G-1
Assistive Care Services and Assisted Living for the Frail Elderly Waiver Services
Fair Hearing Process, continued
Reinstated Benefits
Reinstated or continued benefits must not be reduced or terminated prior to the
final hearing decision unless an additional cause for adverse action occurs while
the hearing decision is pending and the recipient fails to request a hearing after a
subsequent notice of adverse action.
The ALE case manager must inform the recipient or authorized representative in
writing if benefits are reduced or terminated prior to the hearing decision.
Notification of Fair
Hearing Decisions
The hearing officer must send the applicant, recipient, or the authorized
representative a copy of the final order. In addition to describing the final
decision of the hearing, the final order explains:
•
•
The applicant, recipient, or authorized representative can request a judicial
review of the decision and
The applicant, recipient, or authorized representative must pay the cost of
any judicial review.
Time Limit on
Hearing Decision
Federal law requires the final hearing decision must be made and communicated
to all involved parties within 90 calendar days of the hearing request.
Necessary Actions
to be Taken When
Appeal is Granted
Recipient benefit restoration or increases resulting from the final hearing decision
must begin within 10 calendar days of the date the local office is notified. Benefit
increases are effective based on the date specified by the hearings officer.
July 2001
G-2
Jeb Bush
Governor
Alan Levine
Secretary
2727 Mahan Drive
Tallahassee, FL 32308
http://ahca.myflorida.com

Florida Medicaid - Senior Resource Alliance

Transcription

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