59G-13.080: Home and Community-Based Services Waivers
59G-13.083: Developmental Disabilities Waiver Services
PURPOSE AND EFFECT: The purpose of the rule amendment to Rule 59G-13.080, F.A.C., is to delete the reference to the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook and other obsolete language from the general Home and Community-Based Services (HCBS) Rule. We are deleting references to individual waiver programs from the general HCBS rule as we promulgate a stand alone rule for each waiver program.
The purpose of Rule 59G-13.083, F.A.C., is to incorporate by reference the revised Florida Medicaid Developmental Disability Waiver Services Coverage and Limitations Handbook, July 2007, in a stand alone rule. The handbook revisions include updated agency names, provider definitions, provider qualifications; changes to the Core Assurances; and updated service definitions in accordance with Senate Bill 1124 and proviso language in the 2007-2008 General Appropriations Act.
The effect of the rule amendment to Rule 59G-13.080, F.A.C., is to delete the reference to the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook and other obsolete language from the general Home and Community-Based Services (HCBS) Rule. The effect of Rule 59G-13.083, F.A.C., is to incorporate by reference the revised Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, July 2007.
SUBJECT AREA TO BE ADDRESSED: Home and Community-Based Services Waivers and Developmental Disabilities Waiver Services.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.906, 409.907, 409.908, 409.910, 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:
TIME AND DATE: Wednesday, August 15, 2007, 2:00 p.m. – 4:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room A, Tallahassee, Florida 32308
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Pam Kyllonen, Medicaid Services, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, (850)414-9756, kyllonep@ahca.myflorida.com
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
59G-13.080 Home and Community-Based Services Waivers.
(1) though (5) No change.
(6) Program Requirements – General. All HCB services waiver providers and their billing agents must comply with the provisions of the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, October 2003, which is incorporated by reference and available from the Medicaid fiscal agent. The following requirements are applicable to all HCB services waiver programs:
(a) through (i) No change.
(7) through (8) No change.
(9) Home and Community-Based Services Waiver Programs. The following are authorized HCB services waivers: Adult Cystic Fibrosis Waiver, Adult Day Health Waiver (a) Aged and Disabled Adult Waiver; Alzheimer’s Disease Waiver, Assisted Living for the Elderly Waiver, (b) Channeling Waiver; (c) Consumer-Directed Care Waiver, Developmental Disabilities Services Waiver; Family Supported Living Waiver, Familial Dysautonomia, (d) Model Waiver; Nursing Home Diversion Waiver, (e) Project AIDS Care Waiver, and Traumatic Brain Injury and Spinal Cord Injury Waiver.
(10) Aged/Disabled Waiver.
(a) Program Summary. The aged/disabled waiver is a long-term care initiative providing HCB services to the aged and disabled as an alternative to institutional care. Services are available statewide to recipients who meet the eligibility requirements as specified in paragraph (10)(c) of this rule.
(b) Covered Services and Provider Qualifications. Providers must meet the criteria specified in Chapter 59G-5, F.A.C. In addition, providers must be under contract with the Department for the provision of HCB services available under this waiver. Provider qualifications for services are:
1. Adult Day Health Care providers must be licensed adult day health care centers in accordance with Rule 59A-16.003, F.A.C.
2. Caregiver Training and Support providers must be community care for the elderly (CCE) agencies or be Medicaid-participating home health agencies pursuant to Chapter 59A-8, F.A.C.
3. Case Aide providers must be CCE agencies, pursuant to Chapter 410, F.S.
4. Case Management providers must be CCE contractors, or community care for the disabled adults contractors, or staff of the Department who serve the community care for the disabled adults program, pursuant to Chapter 58C-1, F.A.C.
5. Chore Services providers must be community action agencies or home repair services, pursuant to Chapter 10A-10 F.A.C.
6. Consumable Medical Supplies must be provided by medical supply companies, home health agencies, or licensed independent vendors.
7. Counseling providers must be licensed psychologists or mental health counselors pursuant to Sections 490.001-.015, F.S., licensed social workers pursuant to Sections 491.002-.015, F.S., or licensed mental health centers, pursuant to Sections 394.65-.907, F.S.
8. Environmental Modifications providers must be community care agencies as defined in Chapter 10A-10 F.A.C., or independent contractors holding local occupational licenses. If major structural modifications are required, the providers must comply with Chapter 61G4-15, F.A.C.
9. Home Delivered Meals providers must be Older Americans Act and Community Care Meal providers that comply with Sections 410.011-.029, F.S., and Chapter 58C-1, F.A.C.; or Section 410.402 or Sections 410.602-.606, F.S.
10. Homemaker and Personal Care Services providers must be Medicaid participating home health agencies or CCE agencies, pursuant to Chapter 59A-8, F.A.C. or Sections 400.461-.506, F.S.
11. Occupational Therapy providers must be occupational therapists licensed in accordance with Chapter 468, F.S.
12. Personal Emergency Response System providers must be independent contractors that comply with Sections 410.604-.606, F.S.
13. Physical Therapy providers must be physical therapists licensed in accordance with Chapter 486, F.S.
14. Respite Care providers must be licensed Medicaid participating home health agencies, CCE agencies, or residential providers, pursuant to Sections 400.011-.332, 400.401-.454, and 400.616-.629, F.S.
15. Risk Reduction Services providers must be community care agencies, Medicaid participating home health agencies, or independent contractors, pursuant to Chapter 61F11-4, F.A.C.
16. Speech Therapy providers must be speech pathologists licensed in accordance with Sections 468.1105-.1315, F.S.
(c) Recipient Eligibility. Individuals must meet Medicaid eligibility requirements as defined by Chapter 409, F.S., subsection 65A-1.711(4), F.A.C., and Florida’s Title XIX State Plan; or be physically disabled or aged as defined by Rule 65A-1.701, F.A.C., and 42 CFR 435.217 and 435.726, as of October 1, 2001, the latter two hereby incorporated by reference. Recipients must be assessed as meeting level of care criteria for skilled or intermediate nursing home care as defined in Rules 59G-4.180 and 59G-4.290, F.A.C., and must be at risk for nursing facility placement without the provision of HCB services.
(d) Program Operations. The HCB services program under this waiver shall comply with the provisions of Chapters 10A-4, 58A-5, 65C-2, 65C-6, 58C-1, 58A-1, and 58A-14, F.A.C.
(10)(11) Channeling Waiver.
(a) Program Summary. The Channeling program is directed toward a group of seriously impaired, aged Medicaid eligible individuals. The core functions of outreach, screening, assessment, care planning, and case management focus community services on program participants as an alternative to institutional care.
(b) Covered Services and Provider Qualifications. The Agency contracts with qualified entities for the provision of these services to enrolled recipients. The standards applicable to the contractor’s selection of vendors and providers of covered services are outlined in the contract between the Agency and the contractor. The following services are available:
1. Adult Day Health Care;
2. Caregiver Training and Support;
3. Companion Services;
4. Consumable Medical Supplies;
5. Financial Education and Protection Services;
6. Home Health Aide Services;
7. Homemaker and Personal Care Services;
8. Housekeeping/Chore Services;
9. Medical Alert and Response Service;
10. Mental Health Services;
11. Minor Physical Adaptations to the Home/Home Modification;
12. Occupational Therapy;
13. Physical Therapy;
14. Respite Care;
15. Skilled Nursing;
16. Special Home Delivered Meals;
17. Special Drug and Nutritional Assessments;
18. Speech Therapy; and
19. Waiver Case Management.
(c) Recipient Eligibility. Recipients eligible for services under this waiver must be Broward or
(d) Provider enrollment is accomplished through the contract procurement process as set forth in Chapter 287, F.S., and Chapter 13A-1, F.A.C.
(e) Payment Methodology. Payment is based on a prospective monthly per diem reimbursement rate with a year-end cost settlement. Medicaid will make monthly payment to the contractor for satisfactory performance of duties and responsibilities as set forth in the contract. The per diem rate is set annually as a part of the agreement renewal process. The rates are developed using historical Channeling Project data for similar services in the same geographic area, adjusted for anticipated service and cost increases. The final amount paid shall not exceed the amount that would have been paid, on an aggregate basis, by Medicaid under fee-for-service for institutional care provided to a demographically similar population of recipients.
(12) Developmental Services Waiver – General. This rule applies to all Developmental Services Waiver Services providers enrolled in the Medicaid program. All Developmental Services Waiver Services providers enrolled in the Medicaid program must comply with the Developmental Services Waiver Services Florida Medicaid Coverage and Limitations Handbook, October 2003, incorporated by reference, and the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081, October 2003. Both handbooks are available from the Medicaid fiscal agent. The Developmental Disabilities Waiver Services Provider Rate Table, November 2003, is incorporated by reference. The Developmental Disabilities Waiver Services Provider Rate Table is available from the Medicaid fiscal agent.
(11)(13) Model Waiver.
(a) Program Summary. The model waiver allows the provision of specified HCB services to persons with degenerative spinocerebellar disease. These services are provided to eligible persons who would otherwise require the level of care provided in an acute care hospital.
(b) Services Availability. Eligible program participants may receive covered services if approved by the case manager as part of a service plan developed in accordance with the requirements outlined in this section.
(c) Recipient Eligibility. Individuals eligible for HCB services under the model waiver must be:
1. Persons under 21 years of age, disabled with a degenerative spinocerebellar disease as identified in the International Classification of Diseases, 9th Revision (ICD-9), 1995 Edition, effective October 1, 1994, code range beginning with the first three digits of 330 through 337, inclusive; hereby incorporated by reference;
2. Assessed as being at risk of hospitalization by the comprehensive assessment and review for long term care services (CARES) team, administered by DOEA; or the multi-handicapped assessment team (MHAT), administered by the Department’s children’s medical services program; and able to live safely at home with the Medicaid HCB services made available to him; and
3. Cost-effective to the state for each individual program participant, pursuant to the approved federal waiver.
(d) Covered Services and Provider Qualifications. Provider qualifications for services available under this waiver are:
1. Case Management providers must be licensed as a registered nurse in the state of
2. Respite Care providers must be a
(14) Project AIDS Care.
(a) Program Summary. The Project AIDS Care waiver provides a range of HCB services designed to meet the needs of people living with AIDS related conditions.
(b) Covered Services and Provider Qualifications. Providers of AIDS waiver services must be enrolled Medicaid providers, subject to the requirements of Chapter 59G-5, F.A.C. Additional provider qualifications for services available under this waiver are as follows:
1. Adaptive Equipment providers must be handymen, home repair general contractors, licensed general contractors, or medical supply and equipment vendors.
2. Case Management. Case management agency providers must be licensed hospitals, insurance companies, community based AIDS service organizations, or entities of the HRS or the Agency.
a. Case management agencies must meet the following general standards:
(I) Have sufficient qualified case management support and administrative staff to meet service demands in their service area;
(II) Have data collection and analysis capability that will enable the tracking of recipient service utilization, cost, and demographic information;
(III) Have a medical records system that complies with the guidelines of the HRS Pamphlet 150-8, “Guidelines for Clinical Records Management in County Public Health Units”;
(IV) Maintain all accounting and business records according to accepted accounting principles and in sufficient detail to constitute a clear audit trail to justify Medicaid reimbursement for all services;
(V) Require case managers to maintain case loads that are equal to or less than the maximum set by the Medicaid Agency; and
(VI) Comply with state licensure and certification requirements appropriate to the type of provider.
b. In addition to subparagraphs 1. through 6. above, community-based AIDS service organizations must also meet the following standards:
(I) Be organized for the primary purpose of providing health, social, or support services to persons with HIV disease;
(II) Be incorporated as a
(III) Have a Board of Directors consisting of at least five members;
(IV) Have been an operational entity for at least two years;
(V) Have a full-time administration consisting of regularly scheduled and maintained hours of operation, at least a full-time executive director, and sufficient support staff to manage the agency;
(VI) Have an agency director with at least a baccalaureate degree from an accredited college or university in a social science area or a baccalaureate degree and at least two years experience in the social services field;
(VII) Have written operating policies and procedures that address:
(A) Compliance with civil rights/handicapped statutes;
(B) Fiscal operations;
(C) Conflicts of interest;
(D) Prodedures for provision of case management services;
(E) Confidentiality; and
(F) Continuing education.
(VIII) Maintain personnel policies and procedures that assure that case managers will be able to provide waiver case management. This includes:
(A) Position descriptions that include background and education requirements; and
(B) Signed statements by employees acknowledging their obligations to protect confidential information.
(C) Requirements for Case Managers. Case managers must be graduates of accredited colleges or universities with at least a baccalaureate degree in a social science; or, be a licensed registered nurse in the state of
3. Chore Services providers must be handymen or licensed pest control companies.
4. Consumable Medical Supplies providers must be a Medicaid certified home health agency, hospice, Medicaid participating pharmacy provider, or medical supply vendor.
5. Day Health Care providers must be licensed by the state as child and adult day health care centers, including prescribed pediatric extended care centers. These pediatric extended care centers are day stay facilities for ambulatory pediatric patients and are state licensed, pursuant to Chapter 10D-102, F.A.C.
6. Education and Support providers must be community mental health centers licensed by the state pursuant to Chapter 394, F.S., or hospices, or the following licensed professionals: mental health counselors, marriage and family therapists, social workers, and psychologists.
7. Homemaker Services providers must be a licensed, enrolled Medicaid provider, and participating home health agency, hospice, or community-based AIDS service organization that has met the standards for enrollment as case management agencies and that provides training to the homemakers including: confidentiality, infection control, interpersonal skills, basic AIDS education, cultural sensitivity, substance abuse, death and dying, and professional roles and responsibilities.
8. Home Delivered Meals providers must meet all local regulatory requirements for the preparation, packaging, and delivery of home delivered meals.
9. Home Modifications providers must be general contractors, handymen, or home repair services. Modifications that require a building permit will be performed only by state licensed general contractors.
10. Personal Care Services providers must be a licensed and Medicaid participating home health agency or hospice. Duties are assigned and performed under the supervision of a registered professional nurse or other appropriate professional.
11. Respite Care providers must be state licensed and Medicaid participating hospitals, hospices, home health agencies, or day health care centers; or registered nurses licensed under Chapter 464, F.S.
12. Specialized Personal Care Services to Foster Care Children providers must be state licensed foster homes, group homes, or shelter care homes.
13. Skilled Care providers must be an appropriately licensed nurse-employee of a state licensed and Medicaid certified home health agency, a hospice, a state Title V agency (including county public health units), or a licensed respiratory therapist.
14. Substance Abuse Treatment providers must be licensed community mental health centers, licensed drug abuse treatment centers, or individuals who are licensed by the state pursuant to Chapter 490, F.S., or Chapter 491, F.S., as psychologists, mental health counselors, clinical social workers, or marriage and family therapists.
(c) Recipient Eligibility. Recipients eligible for services under this waiver shall:
1. Be categorically eligible or financially eligible under the institutional care program as defined by Chapter 10C-8, F.A.C., and 42 CFR, sections 435.217 and 435.726.
2. Be diagnosed as having AIDS;
3. Be assessed by the CARES team as being at-risk of hospitalization or at-risk of institutionalization in a nursing facility, pursuant to Rules 59G-4.290 and 59G-4.180, F.A.C.;
4. Be determined by the HRS or by the Social Security Administration to be disabled according to Social Security Administration standards;
5. Be able to be maintained safely in the home; and
6. Have a Project AIDS Care case manager.
(d) Provider Enrollment. Pursuant to the requirements of Chapter 59G-5, F.A.C., providers seeking enrollment must complete a Medicaid agreement, and a Medicaid non-institutional provider agreement. To enroll a person not in a licensed profession, the case management agency must submit a letter of reference from a current or past employer, attesting to the person’s character and their professional skills, knowledge, and capability to meet the demands of the position.
(e) Program Operations.
1. Case Management Activities.
a. Project AIDS Care services identified in plans of care and costing less than a total dollar amount set by the Medicaid office may be authorized by the case manager without prior approval from Medicaid.
b. If the total estimated cost of Project AIDS Care services exceeds a level prescribed by the Medicaid office, prior approval must be obtained from Medicaid before service authorizations can be made. This approval will be made after consultation with the case manager and a review of the recipient’s condition, service needs, and the variety and quantity of planned services.
c. The case manager will notify the Medicaid office within seven working days of the recipient’s enrollment. Upon request, case managers will send plans of care to the Medicaid office.
d. The case manager will review plans of care on an ongoing basis, but no less frequently than every six months.
e. Service Authorization. The case manager shall develop written service authorizations for all services except case management. These authorizations will provide sufficient information to allow the provider to bill for services with a minimum of assistance. The authorizations will parallel the plans of care in terms of specificity of the service, the duration of the service, frequency of service, and the total authorized amount to be spent. If a case manager authorizes a service orally, he will send a written authorization to the provider within five working days as confirmation of the oral authorization.
2. Participating case management agency files shall contain at least the following:
a. Notice of Medicaid recipient eligibility;
b. Level of care determination;
c. Project AIDS Care application;
d. Needs assessment;
e. Progress notes;
f. Plans of care; and
g. Service authorizations.
3. Other participating provider agency files shall contain at least the following:
a. Service authorizations;
b. Provider eligibility documents; and
c. Provider enrollment documents.
4. Disenrollment of Case Management Agencies. The Agency or its designee will disenroll a case management agency whose performance impairs the agency’s ability to furnish services. The Agency or its designee must provide at least one oral and at least one written warning to the case management agency regarding the implications of their performance. The Agency or its designee will give a written explanation of disenrollment to the case management agency when disenrollment occurs. Disenrolled case management agencies may submit a new application for Medicaid consideration no less than 12 months after the date of disenrollment.
(f) Payment Methodology. Medicaid will make payment for services provided to Project AIDS Care recipients in accordance with applicable Medicaid claims processing requirements.
(15) Assistive Care Services and Assisted Living for the Elderly Waiver. All Assistive Care Services and Assisted Living for the Elderly Waiver providers must comply with the provisions of the Florida Medicaid Assistive Care Services and Assisted Living for the Elderly Waiver Coverage and Limitations Handbook, July 2001, which is incorporated by reference and available from the Medicaid fiscal agent.
Specific Authority 409.919 FS. Law Implemented 409.902, 409.906, 409.907, 409.908, 409.910, 409.912, 409.913 FS. History–New 4-20-82, Formerly 10C-7.527, Amended 3-22-87, 11-23-89, Formerly 10C-7.0527, Amended 1-16-96, 7-23-97, 1-6-02, 10-27-02, 6-11-03, 11-24-03, 1-16-05, 6-23-05, Formerly 59G-8.200, Amended________.
59G-13.083 Developmental Disabilities Waiver Services.
(1) This rule applies to all developmental disabilities waiver services providers enrolled in the Medicaid program.
(2) All developmental disabilities waiver services providers enrolled in the Medicaid program must be in compliance with the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, July 2007, incorporated by reference, and the Florida Medicaid Provider Reimbursement Handbook, Non-Institutional 081 which is incorporated by reference in Rule 59G-13.001, F.A.C. Both handbooks are available from the Medicaid fiscal agent’s website at http://floridamedicaid.acs-inc.com. Click on Provider Support, and then on Handbooks. Paper copies of the handbooks may be obtained by calling the Medicaid fiscal agent at (800)377-8216.
Specific Authority 409.919 FS. Law Implemented 409.906, 409.907, 409.908, 409.912 FS. History–New________.