M E D I C A I D R E F O R M & A P D , BUDGET & H M O Home
as of 3-7-11
FL
House version still includes APD into an HMO model. Both of these versions are
likely to change,
especially if you write or call your FL House Representative and tell them why
APD should not be
placed under the HMO model. Ask them to adopt the Senate version. In addition
to all this,
Governor Rick Scott is proposing over 170 million dollar cut to APD’s annual
budget.
This is nearly 20% REDUCTION.
Summary of Medicaid Proposed House
Committee Bills
as of 3-7-11
(excerpt related to APD only)
I. The House Medicaid proposal consists of two bills:
a. PCB HHSC 11-01 creates a new part and numerous new sections of law in Chapter 409 that will be phased in over a 5-year period.
b.
PCB HHSC 11-02 makes date-specific, conforming changes to current law (e.g., set
expiration dates for certain sections of existing law). The bill also
authorizes some immediate changes in the Medicaid program to prepare for the
transition to managed care.
.........
VI. Specific provisions that apply to developmental disabilities
a. Implementation will begin January 1, 2015, and be complete in all regions by October 1, 2016.
b. Two types of plans
ii. Long-term care plans that only provide home and community based services
iii. HMO’s must be comprehensive plans already under contract in the region.
c. Eligibility
i. Criteria are the same as the current Medicaid waiver program and the program providing intermediate care for the developmentally disabled.
ii. All recipients of these services on the date the plans become available in their region will be eligible to enroll in the Plans.
iii. New enrollees may be added when funds become available.
d. The benefits that will be required of participating plans are substantially the same as those currently offered.
e. To be eligible, a managed care plan must meet certain criteria:
i. Plans must have staff with experience serving persons with developmental disabilities.
ii. Provider service networks must include certain licensed residential providers with 10 years of experience in developmental disabilities.
iii. Plans must involve consumers and families in design and oversight of plans.
iv. Plans must offer a consumer-directed care program option to enrollees.
v. Plans must contract with all applicable residential providers upon implementation of the new program to ensure no disruption in living situations.
vi. Plans must provide 90-days’ written notice to recipients prior to the recipient’s provider being excluded from the plan for failure to meet quality or performance criteria.
f. Payment
i. AHCA will pay plans based on five specific levels of care for enrolled individuals.
ii. APD will perform the initial assessment and assignment of persons into levels of care.
iii. Rates paid to intermediate care facilities and intensive behavior residential habilitation facilities will be determined by AHCA.
g. Residents of Sunland Marianna and Tacachale are exempt from mandatory enrollment in the new program, but may voluntarily enroll if they so choose.
Actual State of FL House of Representatives PCB HHSC 11-01 APD related excerpt from pages 55-59 as of March 7,2011
409.986 Managed long-term care for persons with 1496 developmental disabilities.— 1497
(1) Pursuant to s. 409.963, the agency is responsible for 1498 administering the long-term care managed care program for 1499 persons with developmental disabilities described in ss. 1500 409.986-409.992, but may delegate specific duties and 1501 responsibilities for the program to the Agency for Persons with 1502 Disabilities and other state agencies. By January 1,2015, the 1503 agency shall begin implementation of statewide long-term care 1504 managed care for persons with developmental disabilities, with 1505 full implementation in all regions by October 1, 2016. 1506
(2) The agency shall make payments for long-term care for 1507 persons with developmental disabilities, including home and 1508 community-based services, using a managed care model. Unless 1509 otherwise specified, the provisions of ss. 409.961-409.970 apply 1510 to the long-term care managed care program for persons with 1511 developmental disabilities. 1512
(3) The Agency for Persons with Disabilities shall assist 1513 the agency to develop the specifications for use in the 1514 invitations to negotiate and the model contract; determine 1515 clinical eligibility for enrollment in long-term care plans for 1516 persons with developmental disabilities; assist the agency to 1517 monitor plan performance and measure quality; assist clients and 1518 families to address complaints with the plans; facilitate 1519 working relationships between plans and providers serving 1520 persons with developmental disabilities; and perform other 1521 functions specified in a memorandum of agreement.
Section 29. Section 409.987, Florida Statutes, is created 1523 to read: 1524
409.987 Eligibility.— 1525
(1) Medicaid recipients who meet all of the following 1526 criteria are eligible and will be enrolled in a comprehensive 1527 long-term care plan or long-term care plan: 1528
(a) Medicaid eligible pursuant to s.409.904. 1529
(b) A Florida resident who has a developmental disability 1530 as defined in s. 393.063. 1531
(c) Meets the level of care need including: 1532
1. The recipient's intelligence quotient is 59 or less; 1533
2. The recipient's intelligence quotient is 60-69, 1534 inclusive, and the recipient has a secondary condition that 1535 includes cerebral palsy, spina bifida, Prader-Willi syndrome, 1536 epilepsy, or autistic disorder; or ambulation, sensory, chronic 1537 health, and behavioral problems; 1538
3. The recipient's intelligence quotient is 60-69, 1539 inclusive, and the recipient has severe functional limitations 1540 in at least three major life activities including self-care, 1541 learning, mobility, self-direction, understanding and use of 1542 language, and capacity for independent living; or 1543
4. The recipient is eligible under a primary disability of 1544 autistic disorder, cerebral palsy, spina bifida, or Prader-Willi 1545 syndrome. In addition, the condition must result in substantial 1546 functional limitations in three or more major life activities, 1547 including self-care, learning, mobility, self-direction, 1548 understanding and use of language, and capacity for independent 1549 living. 1550
(d) Meets the level of care need for services in an 1551 intermediate care facility for the developmentally disabled. 1552
(e) Is enrolled in a home and community based Medicaid 1553 waiver established in chapter 393, or the Consumer Directed Care 1554 Plus program for persons with developmental disabilities under 1555 the Medicaid state plan or the recipient is a Medicaid-funded 1556 resident of a private intermediate care facility for the 1557 developmentally disabled on the date the managed long-term care 1558 plans for persons with disabilities become available in the 1559 recipient's region or the recipient has been offered enrollment 1560 in a comprehensive long-term care plan or long-term care plan. 1561
1. The Agency for Persons with Disabilities shall make 1562 offers for enrollment to eligible individuals based on the 1563 waitlist prioritization in s.393.065(5) and subject to 1564 availability of funds. Prior to enrollment offers, the agency 1565 shall determine that sufficient funds exist to support 1566 additional enrollment into plans. 1567
(2) Unless specifically exempted, all eligible persons 1568 must be enrolled in a comprehensive long-term care plan or a 1569 long-term care plan. Medicaid recipients who are residents of a 1570 developmental disability center, including Sunland Center in 1571 Marianna and Tacachale Center in Gainesville, are exempt from 1572 mandatory enrollment but may voluntarily enroll in a long-term 1573 care plan. 1574
Section 30. Section 409.988, Florida Statutes, is created 1575 to read: 1576
409.988 Benefits.-Managed care plans shall cover, at a 1577 minimum, the services in this section. Plans may customize 1578 BILL
benefit packages or offer additional benefits to meet the needs 1579 of enrollees in the plan. 1580
(1) Intermediate care for the developmentally disabled. 1581
(2) Services in alternative residential settings, 1582 including, but not limited to: 1583
(a) Group homes and foster care homes licensed pursuant to 1584 chapters 393 and 409. 1585
(b) Comprehensive transitional education programs licensed 1586 pursuant to chapter 393. 1587
(c) Residential habilitation centers licensed pursuant to 1588 chapter 393. 1589
(d) Assisted living facilities, and transitional living 1590 facilities licensed pursuant to chapters 400 and 429. 1591
(3) Adult day training. 1592
(4) Behavior analysis services. 1593
(5) Companion services. 1594
(6) Consumable medical supplies. 1595
(7) Durable medical equipment and supplies. 1596
(8) Environmental accessibility adaptations. 1597
(9) In-home support services. 1598
(10) Therapies, including occupational, speech, 1599 respiratory, and physical therapy. 1600
(11) Personal care assistance. 1601
(12) Residential habilitation services. 1602
(13) Intensive behavioral residential habilitation 1603 services. 1604
(14) Behavior focus residential habilitation services. 1605
(15) Residential nursing services. 1606
(16) Respite care. 1607
(17) Case management. 1608
(18) Supported employment. 1609
(19) Supported living coaching. 1610
(20) Transportation. 1611
Summary of the FL Senate Medicaid Reform bill as of 2-17-11: Actual .pdf bill here.
Senate Committee Executive Summary (my interpretation and reading so far)
Adds Downs Diagnosis to our program.
Requires monthly payments by Medicaid recipients.
Prevents using a Medicaid service if employer has health care sponsored plan
Requires parental income based fee for DD kids in HCBS waivers.
Require AHCA to apply to modify Federal Waiver & run limited managed care if denied
Requires all Medicaid recipients to be enrolled in Medicaid managed care
Prevents Medicaid recipient from enrolling in managed care if has employer sponsored HC.
Plans require Primary care providers to get same Medicare rate
APD required to develop / implement a comprehensive redesign the program
AHCA can impose and collect fees from recipients if approved by Medicare s. 409.906(13)(d)
AHCA/APD given power to chg rates, # of services, limit enrollment based on funds available.
***Exempts DD persons as defined under F.S.393.63 from receiving medical services under managed care program.