64F-19.001: Definitions
64F-19.002: Eligibility
64F-19.003: Certification and Authorization
64F-19.004: Enrollment Period
64F-19.005: Waiver Program Enrollment Process
64F-19.006: Management of Minors
64F-19.007: Non-Covered Services
64F-19.008: Continuation of Services
64F-19.009: Termination of Services
64F-19.010: Due Process for Waiver Applicants and Clients
64F-19.011: Approved Form; Incorporation
PURPOSE AND EFFECT: The Department proposes to amend the existing language in this chapter.
SUBJECT AREA TO BE ADDRESSED: The rule amendments make substantive and grammatical corrections to Rules 64F-19.001 through .011, F.A.C.
SPECIFIC AUTHORITY: 154.011(5), 383.0011(13), 381.0051(7), 409.919 FS.
LAW IMPLEMENTED: 154.011, 381.0051, 383.011, 383.103, 409.9121, 4 09.9122 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE NOTICED IN THE NEXT AVAILABLE FLORIDA ADMINISTRATIVE WEEKLY.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Marie Melton, Infant Maternal and Reproductive Health, 4052 Bald Cypress Way, Bin A-13, Tallahassee, Florida 32399
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
64F-19.001 Definitions.
For the purpose of this rule chapter, the following definitions will apply:
(1) “CHD” means County Health Department.
(2) “Client” means a woman who has been approved and is presently enrolled in the Program.
(3) “Continuation of Services” means the amount of time the Program is funded, based on availability of funds.
(4) “CPT Codes” means the codes used within the FMMIS System.
(5) “Eligibility Determination” means the process of determining if a woman meets the qualifications for enrollment in the Program.
(6) “Enrollment” means the process of being registered in the Program as a client for one (1) calendar year.
(7) “Family Planning Services” means for the purpose of the Program:
(a) Counseling and supply visits;
(b) Initial and annual family planning visits;
(c) Laboratory services;
(d) Other Family Planning Services as prescribed in subsection 59G-1.010(86), F.A.C. and Section 409.905(3), F.S.; and
(e) Treatment of abnormal laboratory results.
(8) “FMMIS” means the Florida Medical Management Information System.
(9) “HMO” means a health maintenance organization.
(9)(10) “Non-Covered Services” means services that are not covered under this waiver.
(10)(11) “The Program” means the Family Planning Waiver Program implemented pursuant to section 1115(a) of the Social Security Act and 42 U.S.C.A §1315(a).
(11)(12) “Waiver Applicant” means a woman who applied for the Program but has neither been approved nor denied.
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.002 Eligibility.
In order to be eligible for family planning services under the Program:
(1) The waiver applicant must have lost full Medicaid eligibility. Client must have had a Medicaid financed pregnancy related claim twenty-four (24) months prior to losing Medicaid eligibility
(2) The waiver applicant Client must be eligible for the Program on or after December 1, 20036;
(3) The waiver applicant Client must be actively seeking family planning services;
(4) The waiver applicant Client must self-declare that she is not pregnant;
(5) The waiver applicant Client must not have had a tubal ligation, hysterectomy or other evidence of permanent sterilization;
(6) The waiver applicant Client must have an income at or below 185% of the current federal poverty level;
(7) The waiver applicant must be a female between age 14 and 55;
(8)(7) The waiver applicant Client shall be required to sign a self-declaration statement of income, and provide proof of specifying all gross income available to the client’s household;
(9)(8) The self-declaration statement shall include a signed acknowledgement that the statement is true and correct; at the time it is made;
(10)(9) The waiver applicant Clients whose labor and delivery was paid for as an emergency service under Medicaid or who did not qualify for Medicaid after the Presumptive Eligibility for Pregnant Women period are not eligible for this Program.
(11) Waiver applicants losing the SOBRA Medicaid categories of MMP, MMT, MRMP or MRMT are passively enrolled in the Program for the first year of eligibility and will need to actively complete an application for the second year of eligibility.
Specific Authority 154.011(5), 381.0011(13), 381.0051(7), 409.919 FS. Law Implemented 154.011 FS. History–New
64F-19.003 Certification and Authorization.
(1) Waiver applicants Client shall give written consent before the CHD can obtain or authorize the release of financial and medical information for the purpose of determining Program eligibility. Eligibility information will be obtained by filling out form DOH 3212 as referenced in Rule 64F-19.011, F.A.C.
(2) Signed consent forms of eligibility for DOH 3212, as referenced in Rule 64F-19.011, F.A.C., must be kept in an administrative file at the CHD that enrolled the client in the Program for a minimum of six (6) years.
Specific Authority 381.0011(13), 381.0051(7), 409.919 FS., 42 CFR 491.10. Law Implemented 409.9121, 409.9122 FS. History–New
64F-19.004 Enrollment Period.
The Program covers only family planning services and consensual outpatient surgical sterilization up through twenty-four (24) months subsequent to the loss of full Medicaid to twenty-four (24) months subsequent to any Medicaid financed pregnancy related service.
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.005 Waiver Program Enrollment Process.
(1) The waiver applicant client must self-declare that she is not pregnant at the time of application.
(2) The waiver applicant client must be actively seeking family planning services.
(3) The waiver applicant must not have had a tubal ligation or a hysterectomy. The application shall include the following information and the client shall meet the following criteria:
(a) The client has lost Medicaid
(b) The FMMIS or subsequent system identifies that a Medicaid pregnancy related service occurred and is tracked through CPT codes within the last two (2) years; and
(c) Clients who were enrolled in a Medicaid HMO must present proof of having had a pregnancy orthe provision of pregnancy related services within the two years prior to losing Medicaid.
(4) The waiver applicant must provide proof of citizenship and identity. Only county health department staff who have completed training in the Program eligibility process will determine eligibility for this Program
(5) The waiver applicant must have an income at or below 185% of the current federal poverty level. Applications for the Program may be mailed or hand delivered by the client.
(6) The waiver applicant must complete and sign the application. A face-to-face interview for eligibility determination is not required
(7) The waiver applicant must have lost full Medicaid and the FMMIS or subsequent system verifies this loss of full Medicaid; A supervisor within the CHD will verify the application and its approval or denial.
(8) The waiver applicant must be age 14 to 55. Approval/denial letters, with a description of the appeal process, must be provided to the applicant by the county health department staff.
(9) Only county health department staff who have completed training in the Program eligibility process will determine eligibility for this Program. Once the client is approved, the client will also receive primary care referral information. She is not required to see a health care professional at the CHD.
(10) Applications for the Program may be mailed or hand delivered by the client to the CHD. Eligibility for this Program must be re-determined annually.
(11) A face-to-face interview for eligibility determination is not required.
(12) A supervisor within the CHD will verify the application and its approval or denial.
(13) Approval/denial letters, with a description of the appeal process, must be provided to the applicant by the county health department staff.
(14) The client who is approved for the program will receive primary care referral information. The client is not required to see a health care professional at the CHD.
(15) Eligibility for this Program must be re-determined annually.
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.006 Management of Minors.
Minors, under age 18, will not receive a notice of eligibility and will have to meet the eligibility determination as outlined under Rule 64F-19.002, F.A.C.
(1) Minors will request to apply if they have lost Medicaid eligibility be required to show proof of a Medicaid financed pregnancy related service.
(2) CHD staff can view the FMMIS system or birth certificates as proof of the pregnancy related service(s).
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.007 Non-Covered Services.
For the purposes of the Program the following services are not covered:
(1) Infertility services; and
(2) Abortion services; and
(3) Vasectomies.
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.008 Continuation of Services.
(1) During the maximum two (2) year eligibility period, a client must reapply at the end of the first twelve (12) month period in order to receive benefits for the second twelve (12) month period, retroactive from .
(2) A client shall become eligible for the Program after she loses Medicaid eligibility more than once if more than one pregnancy occurs.
Specific Authority 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.009 Termination of Services.
(1) Clients who fail to reapply annually will be automatically terminated from the Program.
(2) If a service provider is required to reduce or withhold services to clients due to limitations in resources, the provider must give clients thirty (30) days written notice and provide information and referral services to clients for other Medicaid family planning providers.
(3) The client shall also lose eligibility and be terminated from the Program if:
(a) She becomes pregnant;
(b) She is surgically sterilized;
(c) The client’s household income changes and the new income exceeds 185% of the poverty level at the time of enrollment; or
(d) She becomes eligible for Medicaid.
Specific Authority 154.011(5) FS. Law Implemented 154.011 FS., History–New 8-9-04, Amended_________.
64F-19.010 Due Process for Waiver Applicants and Clients.
(1) Waiver applicants will be afforded fair hearing due process as outlined in 42 CFR 431.200-246.
(2) Waiver applicants and clients shall receive written notice when a decision is made to deny or approve services under the Program. Written notice shall include at a minimum:
(a) A description of the action the agency intends to take;
(b) The reasons for the intended action;
(c) Information about the waiver applicants or clients’ rights to request a hearing;
(d) An explanation of the circumstances under which Medicaid services will continue if a hearing is requested;
(e) A statement that requests for a hearing must be filed with the agency clerk within twenty-one (21) days of receipt of the written notice of agency action;
(f) A statement that the hearing shall occur within ninety (90) days of the request; and
(g) A statement that the final order shall be entered within sixty (60) days of the hearing.
(3) The hearings shall be conducted by tThe Department of Children and Families as outlined in Section 120.80(15), F.S.
(4) Clients suspected of probable fraud shall have their period of advanced notice shortened to five (5) days before the date of action as prescribed in 42 CFR 431.214.
Specific Authority 120.80(15), 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New
64F-19.011 Approved Form; Incorporation.
The following form used by the Department in its dealings with the public is listed as follows and is hereby adopted and incorporated by reference, and can be obtained from the Department office by writing to the Department of Health, Family Health Services, 4052 Bald Cypress Way, Bin #A-13, Tallahassee, FL 32399.
DH 3212, entitled “Health Insurance Application for Extended Family Planning Benefits,” (11/06). 05/04
Specific Authority 120.55(1)(a), 120.55(1)(a), (4), 381.0011(13), 381.0051(7) FS. Law Implemented 381.0051, 383.011, 383.013 FS. History–New