Florida Guardian ad Litem
Medicaid Resources and LinksGuardian ad Litem TrainingsNancy E. Wright, Esq.Newright.law@Medicaid Provider Handbooks You Will Probably Need to Access:Behavioral Health Overlay Services (For Children under 21, based on contract with DCF, Child Welfare and CBC organization)Medical Foster CareSpecialized Therapeutic Services (Foster care and group homes, comprehensive behavioral assessment for children determined by DCF to need out-of-home care or sheltering OR in DJJ with emotional disturbance and at risk for residential placement)Targeted Case Management Services For Children at Risk of Abuse and Neglect (Only certain counties: Broward, Duval, Hillsborough, Martin, Dade, Palm Beach, Pinellas) Under age 18, have parent request services, not getting TCM under another program, meet certification criteria for risk of abuse/neglect)Child Health Check-Up (formerly EPSDT) (Screenings and Immunizations)Child Health Services Targeted Case Management (for Early Steps services to children from birth to 3 and for services provided by CMS Medical Foster Care providers)Community Behavioral Health Services (Most services available to all Medicaid recipients, regardless of age)Early Intervention Services (screenings, evaluations, individual or group sessions for birth to 3 with developmental delay)Home Health Services (allows for private duty nursing and personal care for children under 21)Therapy Services (notes that EPSDT allows for prior authorization of therapy services in excess of limitations for children under 21)Intermediate Care Facility for the Developmentally Disabled (This is NOT a waiver service, but available to any Medicaid recipient who meets the eligibility criteria)Provider General Handbook (includes section on “Medicaid Special Services for Children that allows for prior authorization of a medically necessary service that is not listed in a service-specific handbook. See pages 1-42 and 1-43.)Developmental Disabilities Waiver Services Traumatic Brain Injury and Spinal Cord Injury Waiver ServicesMedicaid ABA (Applied Behavior Analysis) Provider List EligibilityDCF Program Policy Manual Link: Due Process42 USC 1396a(3) “A State Plan for medical assistance must … provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance is denied or not acted upon with reasonable promptness.” 42 CFR 431.205 cites Goldberg v. Kelly, 397 US 254 (1970) Recipient of public benefits is entitled to due process prior to withdrawal of benefits, i.e.:Timely, adequate noticePre-termination evidentiary hearingConfront & cross-examine witnessesPresent evidence & oral argumentImpartial decision-makerWritten decision§409.285, Fla. Stat.?Opportunity for hearing at DCF for denial, reduction or termination of public assistance, or if application is not acted upon within a reasonable time.Fair Hearing AuthorityAdministrative Procedures Act, Chapter 120§120.569 Decisions which affect substantial interests §120.57 Formal and informal hearing procedures DCF Fair Hearing Rules: F.A.C. Rules 65-2.042-2.066Uniform Rules of Procedure F.A.C. Chapter 28-106 Decisions Determining Substantial InterestsFlorida Rules of Civil ProcedureTemplate for Proposed Order: of Medicaid Benefits42 CFR §431.230 If the agency mails the required notice, and the recipient requests a hearing before the date of action, the agency may not terminate or reduce services until a decision is rendered after the hearing (with limited exceptions.) 42 C.F.R. §431.321 Services must be reinstated if the agency action is taken without proper advance notification and the recipient requests a hearing.42 CFR 438.420 Continuation of benefits while MCO appeal is pending IFTimely request for fair hearing (filed within 10 days of MCO notice of action)Termination, suspension, or reduction of a previously authorized course of treatment Services were ordered by an authorized provider Original period covered by the original authorization has not expired; and The enrollee requests extension of benefits. Corrective Action42 C.F.R. §431.246 The agency must promptly make corrective payments, retroactive to the date an incorrect action was taken, and if appropriate, provide for admission or readmission of an individual to a facility if – (a) The hearing decision is favorable to the applicant or recipient; or(b) The agency decides in the applicant’s or recipient’s favor before the hearing. FAC Rule 65-2.066(6) allows a DCF Hearing Officer to authorize retroactive corrective actionFrench v DCF, 920 So. 2d 671 (Fla. 5th DCA 2006)Kurnik v. HRS, 661 So. 2d 914 (Fla. 1st DCA 1995)EPSDT42 USC §1396d(r): EPSDT is defined to include:(1) Screening Services (comprehensive health and developmental history, physical exam, immunizations(2) Vision services, including eyeglasses(3) Dental services, including relief of pain and infections, restoration of teeth and maintenance of dental health(4) Hearing services, including hearing aids AND(5) “Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section [which lists all Medicaid mandatory and optional services] to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.”See also 42 C.F.R. §441.5642 USC §1396d(a)(13): “Medical Assistance” includes “other diagnostic screening, preventive and rehabilitative services, including medical or remedial services recommended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.”Garrido v Dudek, 731 F. 3d 1152 (11th Cir. 2013); K.G. v Dudek, 864 F. Supp. 1314 (S.D. FL 2012) (ABA services for children with ASD)Smith v. Benson, 703 F. Supp. 2d 1262 (S.D. Fla. 2009) (Incontinence supplies)Rosie D. v. Patrick, 410 F. Supp.2d 18 (D. Mass. 2006) (In-home behavioral supports)Collins v. Hamilton, 349 F.3d 371 (7th Cir. 2003) (Long term residential psychiatric)Pittman v. FL HRS, 998 F.2d 887 (11th Cir. 1993) (Organ transplant)Pediatric Specialty Care, Inc. v. Ark. DHS, 293 F.3d 472 (8th Cir. 2002) (Early intervention day treatment)Moore ex rel Moore v Reese, 637 F.3d 1229 (11th Cir. 2011) (Medical necessity applies to EPSDT, but to correct or ameliorate condition)Medical NecessityF.A.C. Rule 59G-1.010(166) “Medically necessary” or “medical necessity” means that the medical or allied care, goods, or services furnished or ordered must:(a) Meet the following conditions:1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;2. 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;3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;4. 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; statewide; and5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.(b) “Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.(c) The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.Administrative FinalityPeoples Gas System, Inc. v. Mason, 187 So. 2d 335 (Fla. 1966) Felder v. Dept. of Mgmt Servs, 993 So. 2d 1031 (Fla. 1st DCA 2008)Delray Medical v. AHCA, 5 So. 3rd 28 (Fla. 4th DCA 2009)Agency Policy ChangesCourts v AHCA, 965 So. 2d 154 (Fla. 1st DCA 2007)Brookwood-Walton County Convalescent Center v. AHCA, 845 So. 2d 223 (Fla. 1st DCA 2003)But see M.B. v APD, 13 So. 3d 509 (Fla. 3d DCA 2009) (Agency’s recent application of detailed rule in existence during previous authorizations was not an impermissible change in non-rule policy requiring adoption of a rule.)Medicaid Managed CareFederal Requirements42 USC §1396u-242 C.F.R. Part 438 (Substantial revisions proposed June 2015. See link: )Managed Care Waiver Application with CMSSee link for copy of all Florida Waiver Applications: RequirementsChapter 409, Parts III (Medicaid) and IV (Managed Care), Fla. Stat.Medicaid Provider HandbooksMedical Necessity RuleContract between MCO and AHCA: Health Child Welfare Member Handbook’s Medical Service Network: Complete Care: COMPLAINTAHCA Complaint Form: ................
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