Home & Community-Based Waiver Program
Petitioner removed from Channeling Program, a Home and Community Based Waiver Program, for repeated failure to allow the case manager to conduct a home visit, Fla. Admin. Code 59G-8.5(11)- 09F-06569
Developmental Disabilities
Petitioner not medically stable and correctly removed from the Home and Community Based Care through the Brain and Spinal Cord Traumatic Waiver Program for failure to meet criteria, Florida Medicaid Traumatic Brain and Spinal Cord Injury Waiver Services Coverage and Limitations Handbook pg. 2-3, 2-17 Fla. Admin. Code 59G-13.130- 09F-04874
Appeal granted. Petitioner’s disability causes him to take up to 6 hours a day for activities of daily living. Therefore, both respondent’s initial rejection of all hours and subsequent offer to provide 4 hours a day of Personal Care Assistance under the Developmental Disabilities waiver, were insufficient. Parents give care, when possible, but they are employed and have physical limitations. Any services over 6 hours would be for supervision and safety, which are not factors of medical necessity, Fla. Admin. Code 59G-4.130, F.A.C. 59G-1.010(166), Home Health Services Coverage and Limitation Handbook, pg. 2-22, 23- 10F-00132
Effective March 1, 2010, the Developmental Disabilities Services Waiver no longer provides personal care assistance to patients under the age of 21. Those services are available under the state plan for all Medicaid recipients.- 09F-08159
Long Term Care Waiver
Action to deny payment to nursing facility for custodial care upheld where Petitioner requested disenrollment from program only after transfer into assisted living facility and after the cut off date. Therefore, Petitioner had no prior authorization for her stay and was responsible for costs to nursing home because disenrollment was not effective until 12:01 a.m. the first day of the second month following the request, 42 C.F.R. §435.712, Fla. Stat. §430.705, Fla. Admin. Code 59G-8.100, F.A.C. 59G-1.010(166)- 09F-02768
Additional nursing hours determined to be medically necessary by medical director of private duty nursing at administrative hearing thereby rescinding agency’s initial denial, Fla. Admin. Code 59G-1.010, F.A.C. 59G4.290- 09F-04929
Petitioner enrolled in a nursing home before disenrolling with Long Term Care Waiver program and was therefore responsible for nursing home costs incurred. Because family claimed disenrollment was attempted one month earlier, the respondent retroactively disenrolled petitioner making them eligible for ICP coverage during the month in question. However, the recipient is not eligible for direct reimbursement from Medicaid and will have to be reimbursed for the privately funded month through the nursing home, 42 C.F.R. §431.200, Fla. Stat. §409.903, Fla. Medicaid Provider General Handbook, “Payment for services”, Fla. Medicaid Nursing Facility Services Coverage and Limitations Handbook, s. 6320, Fla. Medicaid Summary of Services Handbook, “Waiver-Aged/Disabled Adult”- 09F-03489
Petitioner moved to a skilled nursing facility prior to receiving authorization from the provider of Medicaid Long Term Care Waiver program. Petitioner claimed that request for disenrollment was ignored by provider, but had no record of prior request. Denial of payment was upheld based on documented disenrollment date, 42 C.F.R. §435.712, Fla. Stat. §430.705, Fla. Admin. Code 59G-8.100, F.A.C. 59G-1.010(166)- 09F-04029
Petitioner met level of care requirements for program, but was denied coverage due to missing verification of financial eligibility. Respondent claimed Petitioner was disenrolled but could not produce a disenrollment notice. Hearing officer determined the two subsequent notices of financial eligibility, which applied retroactively, and the absence of indicia that petitioner’s health recovered to independent status, foreclosed the possibility of disenrollment. Appeal granted, Fla. Stat. §430.705, Fla. Admin. Code 59G-13.080, F.A.C. 58N-1.009, State of Florida Transmittal #I-07-04-006, April 4,2007- 09F-04311
Petitioner applied for Supplemental Security Income-Related Medicaid ICP benefits. To receive benefits an individual must be either, blind, aged or disabled. Petitioner’s impairment would not render him incapacitated for a period greater than 12 months. Therefore, Social Security denied disability benefits. Because the SS decision is binding on an agency, the Respondent could not make an independent determination and adopted the SS decision. Appeal denied, 20 C.F.R. §416.905, 42 C.F.R. §435.540(a), 42 C.F.R. §435.541, Fla. Admin. Code 59G-4.290, F.A.C. 65A-1.711, F.A.C. 65A-1.710- 09F-07634
To qualify for benefits, Petitioners under 65 years of age must meet the disability criteria of the Social Security Act. Respondent’s denial of ICP Medicaid Benefits for lack of disability was overturned because, the SSA determined Petitioner was disabled and their decision is binding, 20 C.F.R. §416.905, 42 C.F.R. §435.541, Fla. Admin. Code 65A-1.710, F.A.C. 65A-1.702, F.A.C. 65A-1.710- 09F-06393
Respondent failed to produce advance written notice as required by federal regulations. Without the notice or any alternative legal authorities, the agency failed to meet its burden of proof and was responsible for nursing home charges incurred prior to actual disenrollment from Long Term Waiver Program, 42 C.F.R. §431.206, 42 C.F.R. §431.210, 42 C.F.R. §431.211, 42 C.F.R. §431.230, 42 C.F.R. §438.404, 42 C.F.R. §438.408, 42 C.F.R. §438.420, Fla. Admin. Code 65-2.060- 09F-07772
Appeal denied. The most recent plan of care, plus an extra bath a week, takes into consideration Petitioner’s hygiene, nutritional and mobility concerns. Additional services are not medically necessary, Fla. Stat. §409.912, F.S. §409.903(1)(d), F.S. §430.705, Fla. Admin. Code 59G-13.080(1), F.A.C. 58N-1.009(1)(3), F.A.C. 59G-1.010(166)- 09F-05239
Appeal denied. Community spouse requested net income figures be used and more expenses be considered in the budget calculations. The Department deducts only for shelter and utility expenses and uses only gross income. Increases are allowed only for exceptional circumstances, 20 C.F.R. §416.1123, Fla. Admin. Code 65A-1.713, F.A.C. 65A-1.712, F.A.C. 65A-1.716(5), Department’s Integrated Policy Manual, passages 2640.0117, 2640.0119.01 to 2640.0119.04, 165-22 Appendix A-9, A-3.1- 09F-07534
Aged and Disabled Adult Waiver
Denial of Home Delivered Meals Program services is upheld because, caregiver has demonstrated the ability to conduct shopping and meal preparation for himself and Petitioner despite his medical condition, Fla. Stat. §409.913(1)(d), Fla. Admin. Code 59G-13.080, F.A.C. 59G-1.010(166), Florida Medicaid Aged and Disable d Adult Waiver Services Coverage and Limitations Handbook, Ch. 1 and 2, Fla. Medicaid A/DA Waiver Services Coverage and Limitations Handbook (March 2004), pg. 10- 09F-07982
Respite care is intended to provide short-term relief for the recipient’s primary caregiver and is limited in amount, duration and scope to those services described in the recipient’s plan of care, Fla. Stat. §409.815(1), F.S. §409.906(13), Florida Medicaid Aged and Disabled Adult Waiver Services Coverage and Limitations handbook (March 2004), pg. 2-35, 2-42, Fla. Admin. Code 59G-13.080- 09F-05518
In response to the repeated tardiness of the Petitioner’s representative and her use of respite caregivers to perform housekeeping, respondent presented her with a Behavior Management Contract. The representative refused to sign the contract, therefore, efforts to suspend services based on violation of contract were invalid. The respondent could have suspended service after two warnings and 10 days notice under the rules. Since the contract was not signed and the respondent failed to give notice before suspension of services, the appeal is granted, Fla. Stat. §409.815(1), F.S. §409.906(13), Florida Medicaid Aged and Disabled Adult Waiver Services Coverage and Limitations handbook (March 2004), pg. 2-35, 2-42, Fla. Admin. Code 59G-13.080- 09F-05518
Appeal denied. Case Manager issued notice suspending homemaking services after the provider refused to work with Petitioner. However, services were suspended only until another provider could be found. Therefore, Respondent has taken no action to reduce or terminate services, Fla. Admin. Code 65-2.060(1), Florida Medicaid Aged and Disabled Adult Waiver Services Coverage and Limitations handbook (March 2004), pg. 2-28, 2-42- 09F-05759
Petitioner was no longer eligible for home delivered meals because the hired caretaker was available 6 days a week to prepare meals and the husband was available the remaining day. Therefore, meal service was not medically necessary, Fla. Admin. Code 59G-1.010(166), Florida Medicaid Aged and Disabled Adult Waiver Services Coverage and Limitations Handbook (August 2005) “Home Delivered Meals”- 09F-08718
Petitioner was transferred from the Community Care for Disabled Adults Program to the Aged and Disabled Adult Waiver Program after turning 60 years old. Respondent reduced personal care hours without providing the petitioner’s plan of care or recommendation of her treating physician to support its decision. Petitioner lived in a rural area and owned several in-home pets. She requested more hours of homemaker services to complete errands and cleaning. Appeal granted and remanded for reconsideration, Fla. Stat. §410.602, F.S. §410.604, Fla. Admin. Code 65C-2, Aged and Disabled Adult Services Coverage and Limitation Handbook, pg. 2-3, 2-11, 2-28- 10F-00165
Appeal granted. Home Health Aide hours were extended to 15 a week to because of caregiver’s increased responsibilities in caring for her sick husband. The HHA hours will continue until after the reevaluation of caregiver’s other commitments and petitioner’s health. Original approval of 10 hours a week was too drastic a reduction, 42 C.F.R. §440.230(d), Fla. Admin. Code 59G-1.010(166), Home Health Services Coverage and Limitations Handbook (July 2008), “Covered Services, Limitations, and Exclusions”- Home Health Aide Service Requirements and Home Health Aide Services- 10F-00713
Traumatic Brain and Spinal Cord Injury Waiver
Appeal denied. Respondent reduced companion care, under Traumatic Brain and Spinal Cord Injury Waiver Services, by one hour a day. The reduction did not affect the Petitioner’s medical circumstance and companion care services should be performed separately from personal and nursing care, Fla. Stat. §408.301, F.S. §408.302, F.S. §409.919, Fla. Admin. Code 59G-1.010(166)(a)(c), Florida Medicaid Summary of Services Handbook, Traumatic Brain and Spinal Cord Injury Waiver Services.- 09F-08079