59G-13.034: Consumer Directed Care Plus for Florida Medicaid Aged and Disabled Adult Waiver Enrollees
PURPOSE AND EFFECT: The purpose of this proposed new rule, Rule 59G-13.034, F.A.C., is to provide direction for Florida Medicaid Aged and Disabled Adult Waiver recipients enrolled in the Consumer Directed Care Plus program, established pursuant to the Florida Consumer-Directed Care Act, set forth at Section 409.221, Florida Statutes. In particular, this rule provides definitions of key terms, sets requirements for emergency back-up plans, and establishes guidelines for prior authorization of goods and services. In addition, in order to ensure cost-efficient use of funds, the rule establishes a maximum reimbursement rate for certain service providers, and mandates return of certain unspent funds.
SUBJECT AREA TO BE ADDRESSED: Consumer Directed Care Plus for Aged and Disabled Adult Waiver Enrollees.
An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-13.034, F.A.C., will have as provided for under Sections 120.54 and 120.541, F.S.
RULEMAKING AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.221, 409.902, 409.906, 409.907, 409.912, 409.913 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: Thursday, November 3, 2011, 2:00 p.m. – 3:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B Tallahassee, Florida 32308-5407
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Sarala Hermes at the Bureau of Medicaid Services, (850)412-4249. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Sarala Hermes, Medicaid Services, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: (850)412-4249, e-mail: sarala.hermes@ahca.myflorida.com. To download a draft copy of this rule, if available, go to http://ahca.myflorida.com/Medicaid/review/index.shtml
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
59G-13.034 Consumer Directed Care Plus for Florida Medicaid Aged and Disabled Adult Waiver Enrollees.
(1) This rule applies to enrollees in the Florida Medicaid Aged and Disabled Adult Waiver Program participating in the Consumer Directed Care Plus Program, their caregivers and to Consumer Directed Care Plus Consultants.
(2) Definitions.
(a) “Attendant Care Services” means services for a consumer that substitute for the absence, loss, diminution or impairment of a physical or cognitive function. Attendant care services are both supportive and health-related hands-on services specific to the needs of the individual. Attendant care services include skilled nursing care or personal care to the extent permitted by state law and housekeeping activities incidental to the performance of care. This service is authorized only when the recipient’s mental or physical condition requires assistance with medically related needs.
(b) “Budget Allowance” means the monthly amount of funds approved for the consumer to purchase needed, cost-effective goods and services, as set forth in Section 409.221(4)(d), F.S.
(c) “Budget Plan” means the written plan that describes how the consumer intends to use the approved monthly allowance.
(d) “Consultant” means an individual who provides technical assistance to consumers in meeting their responsibilities, as set forth in Section 409.221(4)(c)2., F.S.
(e) “Consumer” means a person who has chosen to participate in the Consumer Directed Care Plus Program, has met the enrollment requirements, and has received an approved budget allowance, as set forth in Section 409.221(4)(c)3., F.S.
(f) “Employee” means an individual rendering services eligible for reimbursement under the Consumer Directed Care Plus Program for whom the consumer is the employer of record.
(g) “Non-licensed Employee” means an individual who is providing services and who does not have an active Florida nursing license, granted pursuant to Chapter 464, F.S.
(h) “Personal Care Services” means services to assist the consumer with activities of daily living, including eating, bathing, dressing, and personal hygiene. Personal care may also include meal preparation and housekeeping incidental to the performance of care.
(i) “Provider” means:
1. A person permitted to render services eligible for reimbursement under the Consumer Directed Care Plus Program for whom the consumer is not the employer of record; or
2. A consumer-employed caregiver for whom the consumer is the employer of record.
(3) Emergency Back-Up Plan for Ventilator-Dependent Consumers.
(a) Consumers who are ventilator-dependent must identify at least one service provider who is willing and able to provide care or service if the regular service provider is not available.
(b) The requirement in paragraph (a) above applies for each of the following types of services: Attendant Care Services, Personal Care Services, and Consumable Medical Supplies.
(4) Prior authorization.
(a) Before any goods or services are provided to a consumer through the Consumer Directed Care Plus Program, the Consumer Directed Care Plus Consultant must review and approve the goods or services, based on the consumer’s plan of care.
(b) Any goods or services not listed the consumer’s approved plan of care must be approved by the Agency for Health Care Administration.
(c) Goods and services not covered in the Florida Medicaid Aged and Disabled Adult Waiver Services Program, as set forth in the applicable Florida Medicaid Aged and Disabled Adult Waiver Coverage and Limitations Handbook, will be approved only upon an adequate showing that the goods or services:
1. Will increase the consumer’s independence or will substitute for human assistance; and
2. Are linked to an assessed need or established goal in the consumer’s plan of care.
(5) Reimbursement limits.
(a) Attendant Care Services and Personal Care Services performed at the same time for the same consumer will not be reimbursed.
(b) The maximum reimbursement rate for a non-licensed employee performing any service is $25.00 per hour or $6.25 per 15-minute unit.
(c) The reimbursement limit in paragraph (b) above does not apply to the following:
1. A home health agency licensed under Chapter 400, Part IV, F.S.;
2. A home health agency licensed under Chapter 400, Part IV, F.S., that meets federal conditions of Medicare participation under 42 CFR 484; and
3. A nurse registry licensed under Section 400.56, F.S.
(6) Return of unspent funds.
(a) Any unspent funds will be returned to the State.
(b) Any unspent funds not earmarked in the consumer’s budget plan for an approved savings purchase will be returned to the State.
Rulemaking Authority 409.919 FS. Law Implemented 409.221, 409.902, 409.906, 409.907, 409.912, 409.913 FS. History– New_________.