Getting LTC Waiver Services
Even though multiple managed care plans administer Florida’s LTC Waiver, all plans must offer the same listed benefits and must comply with federal and state Medicaid law. There are no set caps on covered services except that the service be medically necessary. Ultimately, the goal of the LTC Waiver is to provide an array of HCBS to enable enrollees to live in the community and avoid institutionalization.
STEPS TO GETTING LTC WAIVER SERVICES
STEP 1: WHAT SERVICES ARE COVERED?
All covered services are listed and defined in the LTC Program Coverage Policy. Unfortunately, plans do a poor job of explaining services in their Member Handbooks, particularly where there is some overlap. This is particularly true for the most common - and most needed - services: personal care, adult companion, and homemaker. All three provide non-skilled in-person care and supervision with incidental light housekeeping, but personal care focuses on “hands-on” care, homemaker focuses on routine household care, and companion focuses on supervision and social enrichment. Enrollees can seek a combination of these services, as appropriate.
There are no set caps on services, but services may be denied if it is determined that they are not “medically necessary.”
Make sure to review the list of services and think about what is needed to protect your health, safety and welfare before the Plan of Care is developed.
STEP 2: CARE PLAN MEETING
Within 5 business days of selection of a plan, a case manager employed by the plan should visit you to help you come up with a Plan of Care. You may ask anyone you like to be present during the meeting. Remember that the goal of the program is to provide an array of services that are adequate to allow you to safely stay in your chosen setting.
If you live with others or have volunteer help (called “natural support”), the case manager should fill out a form (the LTC Supplemental Assessment) that sets out how long you can safely be left without supervision and should contact any voluntary caregivers to ask about their daily responsibilities, (like work or taking care of other dependents), whether there are any physical or mental limits on providing care, and how much they are willing to provide support.
STEP 3: ASKING FOR MORE SERVICES DURING THE CARE PLAN MEETING
Case managers often can only approve a limited amount of direct care services. If you need more services, including any skilled services like attendant (nursing) care, ask the case manager whether or not you need a physician prescription and tell the case manager that you would like to submit your request to a higher authority at the managed care plan. Also ask for a written notice of denial if your request is not approved.
You should receive a copy of your Plan of Care. If you are asked to sign it but need more time to review it, you have that right.
STEP 4: ASKING FOR MORE SERVICES AFTER CARE PLAN MEETING
If your Plan of Care does not authorize enough services, you can ask for more at any time by contacting your case manager. It is the case manager’s job to forward your request to the plan. If possible, make your request in writing. While most services do NOT require a physician prescription, it is helpful of your physician would write a letter on your behalf supporting the request.
The plan should respond to a request for services within 7 days by either authorizing or sending a Notice of Adverse Benefit Determination (NABD).
STEP 5: ASKING FOR A PLAN APPEAL
READ YOUR NOTICE! It is not great literature, but you need to try to understand why the decision was made, what to do now, and how much time you have to do it in.
If you would like to challenge the NABD, you must appeal it to the plan. You can submit more documentation and state your objection, and you can ask for a complete copy of your case file.
The plan’s response to an appeal is to send an acknowledgement within 5 days and a written Notice of Plan Appeal Resolution (NPAR) within 30. Often the response is within days. If the decision is still unfavorable, you can ask for an administrative fair hearing.
STEP 6: ASKING FOR A FAIR HEARING
Instructions on how to ask for a fair hearing on on your Notice and on AHCA’s website. Fair hearings are before hearing officers at AHCA’s Office of Fair Hearings and operate under AHCA fair hearing rules. Currently, they are held by phone conference. Fair hearings give both parties - you and the plan - the right to present testimony and evidence.
Your NPAR will tell you how long you have to ask for a fair hearing, where to make the request, and what information to include. It will also tell you how to ask for a complete copy of your case file, which you have a right to receive free of charge to help you prepare your case.
If someone is asking for the fair hearing for you, they will be required to submit a form that authorizes them to speak on your behalf.