Florida Guardian ad Litem



Medicaid or?Medicaid Waiver???????Nancy E. Wright, Esq. Newright.law@GAL Video Training 20151.All Medicaid ProgramsJointly funded by federal and state governmentsState administers, but must submit program details to federal Centers for Medicare & Medicaid Services (CMS) for approvalFor regular Medicaid: State PlanFor Medicaid Waivers: Waiver ApplicationAHCA is single state Medicaid agencyMust comply with Medicaid Act (Title XIX of Social Security Act) and other federal laws (like Americans with Disabilities Act)Designed to serve those with limited income & assets2.Medically NecessaryApplies to all services, in all Medicaid Programs“Medical necessity” is defined by Florida Administrative Code Rule 59G-1.010(166)Protect life, prevent illness or disability, alleviate painConsistent with diagnosis and not in excess of needNot experimentalNo less costly treatmentNot primarily for convenience of client or caregiver3.STATE PLAN MEDICAIDA. State Plan MedicaidStatewideNo cap on enrolleesComparable services for anyone eligible for MedicaidCan select among Medicaid providersAHCA has primary responsibilityLike private health insurance (hospitalization, physician visits) but with a wider range of benefitsB. Mandatory vs Optional ServicesMandatory:Required by Medicaid ActOptional:State can chose to offer or notState can limit service by type, amount, duration or scopeC. State Plan Medicaid Services ?(Not Exhaustive)MandatoryInpatient & outpatient hospitalPhysician & nurse practitioner servicesLabs & x-raysPrenatal care, nurse midwife & family planningEPSDT for under 21Rural health clinicFed Qualified Health CtrNursing facility for over 21Limited home health servicesTransportation to medical careOptionalHCBS (disabilities or chronic medical conditions)Pediatric nursing facilitiesDentalInpt psychiatric for under 21ICF/DDPrescription medicationPersonal care servicesPrivate duty nursingPT, OT, S/LT, RTVision & dental servicesDurable medical equipmentD. EPSDT: Children get Mandatory AND Optional ServicesApplies to under 21Early and Periodic Screening, Diagnosis & TreatmentDiagnosis & treatment necessary 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.” 42 USC §1396d(r)(5) (1989 amendment)E.EPSDT IncludesApplied Behavioral Analysis (ABA) Services for children with Autism Spectrum Disorder (ASD)Incontinent suppliesPersonal Care AssistancePrivate Duty NursingTherapy Services 4.MEDICAID WAIVERA. What Does a Waiver Waive?The federal government can approve certain types of programs that would otherwise violate certain provisions of the Medicaid Act, like:Comparability (a program could apply to only certain people, like the elderly or those with developmental disabilities) Statewidedness (a program could operate only in c ertain parts of the state)Freedom of choice (a program could limit provider choice through managed care)B. Types of Waiver ProgramsHome and Community Based Services (HCBS)Requires level of care for nursing or ICF/DDProvides long-term care servicesIn the home, home-like setting, and communityDesigned to prevent or delay institutionalizationResearch and Demonstration Project WaiverManaged Care WaiverC. Florida’s HCBS Waivers for ChildrenDevelopmental Disabilities “iBudget”APD administers and assessesLong waiting list, but crisis enrollment criteria and preference for children in dependency on reunification, adoption, permanent relative placement or permanent guardianshipModel Waiver (degenerative spinocerebeller disease)AHCA administers; CMS & CMAT assessFamilial Dysautonomia (Riley-Day syndrome)AHCA administers and assessesProject AIDS CareAHCA administers; DOEA assessesD. Florida HCBS Waivers 18 and UpTraumatic Brain & Spinal Cord InjuryDOH administers; DOEA assessesAdult Cystic FibrosisDOH administers; DOEA assessesLong-Term Care WaiverAHCA/Managed Care Organization administers; DOEA PARING STATE PLAN AND WAIVER SERVICES FOR CHILDRENA. STATE PLANPrivate Duty NursingPersonal CareABAOther behavioralSIPPDurable MedicalDD WAIVERCase ManagerGroup home and Supported LivingRespiteSpecialized Mental Health TherapyBehavioral ServicesSupported EmploymentAdult Day Training (sometimes available for under 21)6.Who needs the Waiver?If a child is eligible, an application should be made.Waiver enrollment results in Medicaid eligibility based on child’s finances alone, not parental finances. The DD Waiver and others provide HCBS after the child turns 21; State Plan Medicaid will not.Some services are not available under SP Medicaid, like group home placement and respite. ................
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