TEST YOUR LTC WAIVER KNOWLEDGE (Answer) #Floridasmedicaidreform Shirley has suffered a stroke and has severe paralysis on her left side. She needs long term care in a nursing home. Shirley applies for Florida Medicaid ICP benefits. Shirley resides in a Region which has already rolled out under the LTC SMMC. What answer BEST reflects what Shirley needs to do? A. Apply with the Department of Children & Families for financial approval. B. A above, and Shirley needs a LOC from CARES. C. A and B above, and Shirley may select a Plan while pending financial approval, yet it is not necessary. D. A and B above, and Shirley must immediately enroll with a Plan while pending financial approval to begin Plan case management services. E. A and B above, and after Shirley receives financial approval, she must enroll with a Plan to begin case management services. ANSWER: The BEST answer is E. Shirley must file an application with the Department of Children & Families in order to obtain financial approval for Medicaid ICP (nursing home) benefits. It is also necessary for Shirley to meet medical criteria. And, this medical criteria assessment is performed by CARES, and a LOC (level of care) is issued. These 2 tasks have been routine in every case like Shirleys. However, the action of filing the Medicaid application and the determination of the LOC has triggered other events, creating significant glitches for frail elders like Shirley in the Regions where the LTC SMMC has been rolled out. (Regions 7, 8, 9 and most recently Region 2 and Region 10.) These glitches have created havoc for frail elders families, advocates, and the Long Term Care facilities (nursing homes) .... and even the Managed Care Plans! Look back at the Answer D above. This answer is most certainly INCORRECT. Someone in a nursing home, while pending the determination of financial approval by DCF, is NOT mandated to enroll in a Managed Care Plan. Yet, the system created by the State of Florida is geared to auto-enroll frail elders like Shirley prematurely upon receipt of the DCF application filing and the LOC preparation. So, this group of frail elders -- those who are needing Medicaid ICP benefits and applying for those benefits for the first time -- are being prematurely enrolled in Plans which they have not selected due to the systems inability to distinguish them from others within the LTC SMMC. So, what is going to happen to Shirley? Based upon information we have gathered from Region 8 (rolled out on September 1), Shirley receives a notice from AHCA stating she is being auto-enrolled as of a certain date. Lets say this date is November 22. She has been informed that, if she does not select her own Plan, then this Plan in the letter is the Plan that has been selected for her. Yet, the State of Florida has repeatedly stated that Shirley is NOT required to select nor enroll in any Plan until DCF approves her financially for Medicaid ICP. In fact, the State of Florida has stated that the Managed Care Plans can NOT offering ANY case management services while a nursing home Medicaid applicant is pending financial approval. Furthermore, since it often takes 2 or 3 months to obtain the financial approval from DCF, Shirley is being prematurely enrolled in a Plan through this system glitch as much as 8 weeks before she is even approved for Medicaid. Why is this such a serious glitch in #Floridasmedicaidreform ? In addition to Shirleys decision-making being compromised for selection and enrollment into a Plan of her own choice, #AHCA s system is now geared to pay the wrong person for Shirleys care when her Medicaid is approved by DCF. It is geared to pay the Plan and not the nursing home. Before the LTC SMMC, nursing homes sought retroactive payment for Shirleys care up to 3 months prior to the month of application (if permitted by Shirleys financial eligibility). This payment to a nursing home is called a Fee for Service payment. Under the LTC SMMC, this payment to the nursing home is SUPPOSED to remain the same. The way it is supposed to work: The nursing home contacts AHCA and AHCA pays the nursing home for Shirleys Medicaid for those retroactive months while Shirley was pending financial approval on a FFS basis. Once Shirley is approved, then Shirley must select and enroll in a Plan. And, then the Plan begins to receive payment for Shirleys ongoing care in the nursing home based upon a blended rate of payment. The Plan performs case management services and is paid from the blended rate, while the nursing home submits its bill to the Plan to be reimbursed the Medicaid Reimbursement Rate for Shirley while she remains in the nursing home on a long term basis. If Shirley has been incorrectly and prematurely enrolled into a Plan prior to financial approval, then AHCA may deny the payment to the nursing home when the nursing home requests its FFS payment. And, the Plan may be the one getting paid rather than the nursing home even though the Plan has not yet performed any services (and may not even know who Shirley is). There are solutions to this premature enrollment glitch. Yet it takes time and effort by Shirleys advocate to correct this system error. Well discuss those corrective measures in a later post. Yet, Advocates should work closely with the nursing home on Shirleys behalf to keep the system glitch from compromising Shirleys rights and creating these headaches between Shirley, the nursing home and the Plan.
Posted on: Fri, 08 Nov 2013 13:10:00 +0000
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