Fla. Admin. Code Ann. R. 59G-13.080 - Home and Community-Based Services Waivers
(1) Purpose. Under authority of Section 2176
of Public Law 97-35, Florida obtained waivers of federal Medicaid requirements
to enable the provision of specified home and community-based (HCB) services to
persons at risk of institutionalization. Through the administration of several
different federal waivers, Medicaid reimburses enrolled providers for services
that eligible recipients may need to avoid institutionalization. Waiver program
participants must meet institutional level of care requirements. The HCB waiver
services are designed to allow the recipients to remain at home or in a
home-like setting. To meet federal requirements, Medicaid must demonstrate each
waiver's cost-effectiveness.
(2)
Definitions. General Medicaid definitions applicable to this program are
located in Rule
59G-1.010, F.A.C.
Additional descriptions of services available under this program are provided
in subsection (3) of this rule. The following definitions apply:
(a) "Agency" means the Agency for Health Care
Administration, the Florida state agency responsible for the administration of
Medicaid waivers for home and community-based (HCB) services.
(b) "Department" means the Florida Department
of Elderly Affairs (DOEA).
(3) Home and Community-Based (HCB) Waiver
Services are those Medicaid services approved by the Centers for Medicare and
Medicaid under the authority of Section 1915(c) of the Social Security Act. The
definitions of the following services are provided in the respective HCB
services waiver, as are specific provider qualifications. Since several similar
services with different names may be provided in more than one waiver, this
section lists them as a cluster. A general description of each service cluster
is provided. Individuals eligible for the respective HCB services waiver
programs may need and receive the following services:
(a) Adaptive and Assistive Equipment, and
Adaptive Equipment, include selected self-help items that are necessary for
recipient safety and that assist recipients to increase their functional
ability to perform activities of daily living.
(b) Adult Day Health Care and Day Health Care
are services provided in an ambulatory care setting. They are directed toward
meeting the supervisory, social, and health restoration and maintenance needs
of adult recipients who, due to their functional impairments, are not capable
of living independently.
(c)
Caregiver Training and Support are services that encourage the provision of
care for the recipient in the home or home-like settings from caregivers such
as relatives, friends, and neighbors. Activities include workshops or in-home
training conducted by professionals to increase the caregivers' knowledge of
caregiving skills and understanding of the aging or disease process and to
provide emotional support through caregivers' support groups.
(d) Case Aide services are adjunctive to case
management and provided by paraprofessionals under the direction of case
managers. These services include: assistance with implementing plans of care,
assistance with obtaining access to appointments for care plan and other
services, supervision of provider activities, and assisting with linkages of
providers with recipients via additional telephone contacts and visits. They
will not develop care plans or conduct assessments or reassessments.
(e) Case Management, Waiver Case Management,
and Support Coordination are services that assist Medicaid eligible individuals
in gaining access to needed medical, social, educational and other services,
regardless of funding source.
(f)
Chore Services and Housekeeping/Chore Services are provided to maintain the
home in a clean, sanitary and safe environment. Chore services will be provided
only in cases where neither the recipient, nor anyone else in the household, is
capable of performing or financially providing for them, and where no other
relative, caretaker, landlord, community volunteer/agency, or third party payor
is capable of or responsible for their provision.
(g) Companion Services include those
activities necessary to assist the recipient in performing household or
personal tasks and providing social stimulation to relieve the negative effects
of loneliness and isolation.
(h)
Consumable Medical Supplies are expendable, disposable, and non-durable items
used for the treatment of specific injuries or diseases, or for persons who
have chronic medical or disabling conditions. These supplies exceed those
routinely furnished by the provider in conjunction with skilled care and home
health aide visits.
(i) Counseling,
Mental Health Services, Education and Support, and Behavioral Analysis are
services provided for the diagnosis or treatment of mental, psychoneurotic, or
personality disorders, or providing assistance to recipients in identifying
feasible goals, providing emotional support and guidance, providing advice
about community resources, or exploring possible alternative behavior
patterns.
(j) Day Training service
programs support the participation of recipients in daily, valued routines of
the community, which for adults may include work-like settings but exclude
services directed at teaching specific job skills or meeting employment
objectives of non-supported, competitive, paid or unpaid employment in the
general work force. Day training programs for children are limited to children
who, because of age, are not eligible for services through the local education
agencies. Early developmental intervention activities are provided to maximize
the development of the child. This service stresses self-help, adaptive, and
social skills which are age-appropriate for the individual.
(k) Emergency Alert Response, Medical Alert
and Response Service, and Personal Emergency Response Systems are methods of
monitoring persons, through electronic or other means, in their own home to
assure their safety by identifying their need for assistance or medical
intervention and dispatching qualified personnel to the home.
(l) Environmental Modifications, Minor
Physical Adaptations to the Home/Home Modifications, and Home Modifications are
structural changes to the home which are necessary to enhance a recipient's
safety and well-being or to help the recipient to function with greater
independence in the home. These adaptations/improvements must be of direct
medical or remedial benefit to the client.
(m) Financial Education and Protection
Services consist of formal instruction in budget management, sensible
purchasing habits, and financial management skills to make optimum use of
limited financial resources and to avoid exploitation.
(n) Home Delivered Meals and Special Home
Delivered Meals are designed to provide meals to persons who have difficulty
shopping for or preparing food without assistance.
(o) Home Health Aide Services include
therapeutic, supportive, and compensatory health and personal care tasks and
activities for recipients in their homes provided by an aide employed by a
licensed home health agency working under the supervision of a registered
professional nurse or another appropriate health professional.
(p) Homemaker, and Homemaker and Personal
Care Services provide assistance with daily living activities and household
tasks related to supporting clients in a home setting. Services include
assistance with bathing, dressing, eating, maintenance of personal belongings,
and performance of light housekeeping, and meal planning and
preparation.
(q) Non-Residential
Support Services are activities provided in an individual,
community-integrated, non-residential setting. These activities are
age-appropriate and geared to enhance acceptable behaviors, increase the
individual's ability to control the environment, and emphasize those qualities
that are integrative and normative. For adults, these services may be provided
in work-like settings in the community.
(r) Occupational Therapy is the use of
prescribed activities designed for a specific remedial purpose to restore,
improve, or maintain impaired functions for the purpose of increasing or
maintaining independent functioning.
(s) Personal Care Services provide assistance
with, or supervision of, activities of daily living. Personal care services
offer an alternative to home health aide services when a client's condition no
longer requires the attention of a nurse or aide acting under regular
supervision.
(t) Physical Therapy,
is treatment by physical agents or methods to restore, improve, or maintain
impaired bodily functions by massage, exercise, and the use of physical,
chemical, and other properties of motion, heat, electromagnetic radiation,
light, electricity, or sound, as defined in Chapter 486, F.S., incorporated by
reference. In some waiver programs, it may include an assessment.
(u) Private Duty Nursing Services are
individual and continuous care provided by licensed nurses in the recipient's
home.
(v) Residential Habilitation
is assistance with acquisition, retention, or improvement in skills related to
activities of daily living, such as personal grooming and cleanliness, bed
making and household chores, eating and the preparation of food, and the social
and adaptive skills necessary to enable the recipient to reside in a
non-institutional setting.
(w)
Respite Care is the provision of supervisory, supportive, and short-term
emergency care necessary to maintain the health and safety of a recipient when
the primary caregiver is not available to provide such care or requires relief
from the stress and demands associated with daily care.
(x) Risk Reduction services provide care and
guidance to caregivers, based on a plan of specific exercises for the recipient
to increase physical capacity, strength, dexterity, and endurance to perform
activities of daily living. This service also includes assessment and guidance
for the recipient and caregiver to learn to prepare and eat nutritious meals
and promote better health through improved nutrition. This service may include
instructions on shopping for appropriate food, preparation, and monitoring of
same. This service also provides guidance for budgeting and paying bills, which
may include establishing checking accounts and direct deposits to lessen the
risk of financial exploitation and abuse of the recipient.
(y) Skilled Nursing and Skilled Care are
skilled nursing services provided to assure the client's safety and to achieve
the objectives of the physician authorized treatment plan. This care may also
include the services of a licensed respiratory therapist. These skilled
services may be provided in the client's home.
(z) Special Drug and Nutritional Assessments
assure that basic health care needs are being accurately prescribed. Drug
assessments include a review of prescriptions to assure that multiple
medications are being administered correctly. Nutritional assessments include a
review of the recipient's nutritional needs, development of special diets, and
nutrition education of the recipient or caregivers.
(aa) Special Medical Home Care is nursing
care and supervision required by medically fragile persons residing in small
licensed group homes. The service includes 24-hour-a-day nursing
service.
(bb) Specialized Personal
Care Services to Foster Care Children is special care given in foster, group,
and shelter care homes to children with AIDS. Additional care is given to these
children primarily in the areas of monitoring, supervision, disinfection and
stimulation. Payment for this service is exclusive of that paid by the
Department for room and board.
(cc)
Speech Therapy is the provision of services necessary for the diagnosis and
treatment of speech and language disorders that have resulted in a
communication disability.
(dd)
Substance Abuse Treatment includes counseling and therapeutic services by
licensed providers directed to assist substance abusers in understanding and
resolving or ameliorating contributory behavioral patterns or life conditions
and to provide support and assistance to those recipients during this
process.
(ee) Supported Living
Coaching services are provided to recipients living in their own home or
apartment and support them in maintaining an autonomous household in the
community.
(ff) Transportation is
travel to and from service providers or community resources identified in the
service plan. This service is available under the HCB services waiver to enable
recipients to gain access to planned services when transportation to those
services is not otherwise Medicaid compensable.
(4) Covered Services - General. Services
provided under the HCB services waivers include those described in paragraphs
(3)(a) through (ff). The availability of these services to waiver program
participants is subject to approval by the Medicaid office and is subject to
the availability of the services under the specific waiver program for which a
recipient has been determined eligible.
(5) Service Limitations - General. The
following general limitations and restrictions apply to all home and
community-based services waiver programs:
(a)
Covered services are available to eligible waiver program participants only if
the services are part of a waiver plan of care ("care plan", "individual
support plan", or "family support plan"). Care plan requirements are outlined
in subsections (6) and (8) of this rule.
(b) The agency or its designee shall approve
plans of care based on budgetary restrictions, the recipient's necessity for
the services, and appropriateness of the service in relation to the recipient,
prior to their implementation for any waiver recipient.
(c) Additional service limitations applicable
to specific waiver programs are specified in subsections (10) through (14) of
this rule.
(6) Program
Requirements - General.
(a) The Medicaid
program will deny an applicant's enrollment request if the proposed enrollment
could cause the program to exceed the maximum enrollment level authorized by
the Health Care Financing Administration in the applicable HCB services
waiver.
(b) A person can not
receive Medicaid waiver services until he is determined eligible, waiver
funding is available, and is enrolled in the appropriate waiver
program.
(c) The Agency or its
designee will conduct home visits of waiver program applicants or participants.
Assessments of the applicant's or participant's home situation will be made to
determine if it is acceptable in providing for his general health or safety. If
the applicant's or participant's home situation does not provide for the
applicant's or participant's general health or safety, the Agency shall
restrict the applicant or participant from participation in the waiver
program.
(d) The Department or its
designee will perform an evaluation of the level of care needed by an applicant
for services when there is a reasonable indication that the applicant might
need institutionalization in the near future, if the covered HCB services were
not available.
(e) The Department
or its designee will perform reevaluations of level of care at least annually,
or as changes in the recipient's condition or community care setting may
warrant.
(f) The plan of care will
identify the type of services to be provided, the amount, frequency, and
duration of each service, and the type provider to furnish each
service.
(g) Reimbursement claims
for the provision of Medicaid services not listed in the plan of care of HCB
services waiver program participants are subject to denial or
recoupment.
(h) In providing
applicants or participants freedom of choice, the Agency or its designee must:
1. Inform all prospective waiver program
participants of the feasible alternatives available under the respective waiver
program and afford recipients a freedom of choice to participate in the
community program in lieu of institutional placement;
2. Afford recipients the opportunity to
choose from those enrolled providers capable of providing the covered services
identified in the recipient's plan of care; and
3. Afford all enrolled recipients the right
to disenroll at any time.
(i) The Agency or its designee, will
disenroll waiver program participants who:
1.
Do not follow a recommended plan of care, as evidenced by: not keeping two
consecutive appointments, or demonstrating multiple failures to avail
themselves of offered services.
2.
Demonstrate behavior that is disruptive, unruly, abusive, or uncooperative to
the extent that their participation in the program seriously impairs the
provider's ability to furnish services to the participant or other
participants. Prior to disenrolling participants for the above reasons, the
Agency or its designee must provide the participant at least one verbal and at
least one written warning that the consequence of their actions, or inactions
will be disenrollment from the program.
(7) Provider Qualifications and Provider
Enrollment. To enroll and participate in the waiver programs, providers must
comply with the provisions of Chapter 59G-5, F.A.C. Additional provider
requirements are specified in subsections (10) through (14) of this
rule.
(8) Case Management
Requirements. Case managers advocate for recipients during the eligibility
determination process and assist applicants in complying with requests for
information, interviews, or activities required for a determination of Medicaid
eligibility. Case managers will conduct a comprehensive needs assessment and
identify areas in the person's life that require supports or services to reduce
the risk of having to be placed in an institution. In addition, each case
manager will:
(a) Begin the initial needs
assessment before services are provided and complete it within 30 days of
enrollment in the waiver program;
(b) Make a home visit as part of the needs
assessment process;
(c) Prepare a
written plan of care for each program participant and maintain the plan in the
participant's case record;
(d)
Reassess the plan of care at least every six months to review service goals,
outcomes, and functional changes that may warrant the modification of the plan
and reassessment of the recipient's level of care;
(e) After the needs assessment has been
completed, maintain in each client's record case progress notes that document
the provision of services;
(f) Make
legible entries in the case progress notes in sufficient detail to document the
case management service rendered and to allow an audit of the appropriateness
of charges;
(g) Date and sign all
written case record entries;
(h)
Notify the Agency of all disenrollments by waiver program participants within
30 days after the effective date; and
(i) Maintain records in an accessible
location for review by authorized federal and state representatives for
monitoring and auditing purposes; ensure that recipient specific information is
maintained as "confidential"; ensure that program, administrative, and
financial information is maintained for a period of at least five years after
termination of participation as a waiver service provider. If an audit has been
initiated and audit findings have not been resolved at the end of five years,
the records will be retained until resolution of the audit findings.
(9) Home and Community-Based
Services Waiver Programs. The following are authorized HCB services waivers:
Adult Cystic Fibrosis Waiver; Adult Day Health Waiver; Aged and Disabled Adult
Waiver; Alzheimer's Disease Waiver; Assisted Living for the Elderly Waiver;
Channeling Waiver; Consumer-Directed Care Waiver; Developmental Disabilities
Waiver; Family Supported Living Waiver; Familial Dysautonomia Waiver; Model
Waiver; Project AIDS Care Waiver; and Traumatic Brain Injury and Spinal Cord
Injury Waiver.
(10) Channeling
Waiver.
(a) Program Summary. The Channeling
program is directed toward a group of seriously impaired, aged Medicaid
eligible individuals. The core functions of outreach, screening, assessment,
care planning, and case management focus community services on program
participants as an alternative to institutional care.
(b) Covered Services and Provider
Qualifications. The Agency contracts with the organized health care delivery
system for the provision of these services to enrolled recipients. The
standards applicable to the contractor's selection of vendors and providers of
covered services are outlined in the contract between the Agency and the
contractor. The following services are available:
1. Adult Day Health Care;
2. Caregiver Training and Support;
3. Companion Services;
4. Consumable Medical Supplies;
5. Financial Education and Protection
Services;
6. Home Health Aide
Services;
7. Personal Care
Services;
8. Chore
Services;
9. In Home
Counseling;
10. Medical Alert and
Response Service;
11. Mental Health
Services;
12. Minor Physical
Adaptations to the Home/Home Modification;
13. Occupational Therapy;
14. Physical Therapy;
15. Respite Care;
16. Skilled Nursing;
17. Special Home Delivered Meals;
18. Special Drug and Nutritional
Assessments;
19. Special Medical
Equipment;
20. Special Medical
Supplies;
21. Speech Therapy;
and
22. Waiver Case
Management.
(c)
Recipient Eligibility. Recipients eligible for services under this waiver must
be Broward or Dade County residents, 65 years of age or older, and eligible
under the HCB services waiver optional coverage groups as defined by 42 CFR
section 435.217, or otherwise be Medicaid eligible. Recipients must be assessed
as meeting level of care criteria for skilled or intermediate nursing home care
as defined in Rules
59G-4.290 and
59G-4.180,
F.A.C. The contractor may refuse participation in the program to otherwise
qualified recipients whose estimated cost of community care exceeds 85 percent
of the cost of institutional care in that recipient's county of
residence.
(d) Provider enrollment
is coordinated by the Channeling provider.
(e) Payment Methodology. Payment is based on
a prospective monthly per diem reimbursement rate. Medicaid will make monthly
payment to the contractor for satisfactory performance of duties and
responsibilities as set forth in the contract. The per diem rate is set
annually as a part of the contract renewal process. The rates are developed
using historical Channeling Project data for similar services in the same
geographic area, adjusted for anticipated service and cost increases.
(11) Model Waiver.
(a) Program Summary. The model waiver allows
the provision of specified HCB services to persons with degenerative
spinocerebellar disease. These services are provided to eligible persons who
would otherwise require the level of care provided in an acute care
hospital.
(b) Services
Availability. Eligible program participants may receive covered services if
approved by the case manager as part of a service plan developed in accordance
with the requirements outlined in this section.
(c) Recipient Eligibility. Individuals
eligible for HCB services under the model waiver must be:
1. Persons under 21 years of age, disabled
with a degenerative spinocerebellar disease as identified in the International
Classification of Diseases, 9th Revision (ICD-9), 1995 Edition, effective
October 1, 1994, code range beginning with the first three digits of 330
through 337, inclusive; hereby incorporated by reference;
2. Assessed as being at risk of
hospitalization by the comprehensive assessment and review for long term care
services (CARES) team administered by DOEA; or the Children's Multidisciplinary
Assessment Team (CMAT), administered by the Department of Health, Children's
Medical Services; and able to live safely at home with the Medicaid HCB
services made available to him; and
3. Cost-effective to the state for each
individual program participant, pursuant to the approved federal
waiver.
(d) Covered
Services and Provider Qualifications. Provider qualifications for services
available under this waiver are:
1. Case
Management providers must be licensed as a registered nurse in the state of
Florida and meet applicable state requirements, pursuant to Chapter 464,
F.S.
2. Respite Care providers must
be a Florida licensed and Medicaid participating home health agency and meet
applicable state requirements, pursuant to Chapter 400, F.S.
(12) Assistive Care
Services and Assisted Living for the Elderly Waiver. All Assistive Care
Services and Assisted Living for the Elderly Waiver providers must comply with
the provisions of the Florida Medicaid Assistive Care Services and Assisted
Living for the Elderly Waiver Coverage and Limitations Handbook, July 2001,
which is incorporated by reference and available from the Medicaid fiscal
agent's Web Portal at http://mymedicaid-Florida.com. Click on Public
Information for Providers, then on Provider Support, and then on Provider
Handbooks. Paper Copies are available by calling the Provider Contact Center at
800-289-7799 and selecting Option 7.
Notes
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