ACCESS or MyACCESS: The online portal operated through Florida Department of Children and Families for access to Medicaid and other public benefits.

AHCA, pronounced ah-kah: Agency for Health Care Administration. The single Florida agency with overall responsibility for all Medicaid programs. 

AHCA Medicaid Complaint: Medicaid recipients can file a complaint with AHCA either online or verbally. If the complaint is being filed by someone other than the recipient or the recipient’s legal representative, an AHCA HIPAA release should be provided so that the AHCA complaint counsel can speak with the filer.

APD (iBudget): Agency for Persons with Disabilities. Florida agency that administers the Medicaid program (called “iBudget”) that delivers home and community-based services to people with developmental disabilities. 

CARES: Comprehensive Assessment and Review for Long-Term Care Services: A division of DOEA that does assessments to determine the level of care for the LTC Program.  

Case Manager or Care Coordinator (LTC Waiver): The case manager is employed by the managed care plan and is responsible for providing information to help enrollees access LTC Waiver services, develop a person-centered plan of care and provide ongoing coordination of services and advocacy.

CDC+ (iBudget): Consumer Directed Care Plus. An APD program for people enrolled in the Medicaid iBudget Waiver that allows for more choice in hiring providers and flexibility in how approved funds are used. 

CMS: Centers for Medicare & Medicaid Services. Federal agency under the Department of Health & Human Services with oversight over Medicaid, Medicare, and Children’s Health Insurance Program.

CMS: Children’s Medical Services. A specialty plan under Basic Medicaid for children with complex medical needs.  

DCF: Department of Children & Families. Florida agency responsible for determining financial eligibility for Medicaid programs.

Developmental Disability (iBudget): For purposes of eligibility for iBudget or authorization of placement in an ICF, the applicant must meet Florida’s definition of “developmental disability.” Be aware that Florida’s definition is more restrictive and sometimes out of date with the definitions and criteria used by clinical professionals when diagnosing a developmental disability.

Florida Statute §393.063(11) defines “developmental disability” as

• a disorder or syndrome that is attributable to intellectual disability, cerebral palsy, autism, spina bifida, Down syndrome, Phelan-McDermid syndrome, or Prader-Willi syndrome;

• that manifests before the age of 18;

• and that constitutes a substantial handicap that can reasonably be expected to continue indefinitely.

Most of the listed categories of developmental disabilities are medical conditions that would require a medical diagnosis to establish eligibility. Intellectual disability and autism, however, do not have a distinct “cause” but are evaluated by history, psychological testing, and symptoms. These disorders are typically diagnosed by psychologists or psychiatrists using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (“DSM”). The DSM criteria for both intellectual disability have evolved since the State’s definitions were set out in statute and rule. Applicants need to be aware that they can show that the State’s criteria has been met even if they have been diagnosed.

Autism: Defined in Florida statute and rule as requiring that the applicant’s condition meet all of the following:

• Pervasive, meaning always present without interruption

• Neurologically based, meaning not the result of a physical impairment

• A developmental disability with age of onset during infancy or childhood

• With extended duration, meaning that the condition reasonably can be expected to continue indefinitely into the future

• Causes severe learning disorders resulting in both severe communication disorders affecting both verbal and nonverbal skills, and severe behavior disorders. This section is further defined by rule to require 6 out of 12 listed features of autism related to communication or behavior, with at least one in the behavior category. Rule 65G-4.014(1)(e), Fla. Admin. Code should reviewed to make sure that evaluators look to these specific factors when doing an assessment of the applicant.

  Intellectual Disability: Defined in Florida statute as:

• Significantly subaverage general intellectual functioning (meaning performance that is two or more standard deviations from the mean score on a standardized intelligence test specified in the rules of the agency)

• Existing concurrently with deficits in adaptive behavior (meaning the effectiveness or degree with which an individual meets the standards of personal independence and social responsibility expected of his or her age, cultural group, and community)

• Which manifests before the age of 18 and

• Can reasonably be expected to continue indefinitely.

• Applicants should review how Intellectual Disability is further defined in Rules 65G-4.014(3) and Fla. Admin. Code and 65G-4.017(3), particularly with regard to how IQ test results are reviewed.

DOEA: Department of Elder Affairs. Florida agency that manages the waitlist for the Long-Term Care Waiver and oversees screening for nursing home level of care through its “CARES” Division. 

Dual Eligible: Someone who is enrolled in both Medicaid and Medicare. 

EPSDT: Early & Periodic Screening, Diagnosis, and Treatment. A comprehensive basic Medicaid benefit for children (under age 21) requiring states to provide all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions. EPSDT includes some very important benefits that are not available to adults through basic Medicaid, including home health care (private duty nursing, personal care assistance, and home therapies), behavioral services, and consumable medical supplies.  

HCBS: Home and Community-Based Services. For Medicaid purposes, HCBS are those long-term services and supports that are intended to meet the needs of people who are transitioning from an institution or to delay or prevent entry into an institution. Generally, basic Medicaid offers few benefits that would be classified as HCBS (except for children under 21. See EPSDT.) However, states have the ability to operate Medicaid HCBS programs (See HCBS Waivers) directed toward selected populations that might otherwise require institutional care. Some examples of HCBS include direct staff to help with self-care, supervision, community engagement, and employment; training programs to increase independence; housekeeping services; therapies; and transportation.

HCBS Waivers: Under federal law, states can craft programs to provide HCBS to people who would otherwise need an institutional level of care. While each state can define who is eligible and submit their own administration plans, all programs are subject to federal Medicaid law and regulations. HCBS Waivers are jointly federal-state funded.

What does a Waiver waive? The Medicaid Act allows the federal government to waive some of the requirements for basic Medicaid, like comparability (having to give medically necessary services to anyone who needs them regardless of diagnosis) and not have caps on enrollment.

iBudget: The Florida HCBS Waiver program for people age 3 and up who have certain statutorily defined developmental disabilities and would otherwise need an ICF level of care. The full name is “Developmental Disabilities Individual Budgeting Waiver.”

iBudget Waiver Services: Defined in the Developmental Disabilities Individual Budgeting Services Coverage and Limitations Handbook, iBudget offers the following services:

Life Skills Development (Companion, Supported Employment and Adult Day Training) Supplies and Equipment (Consumables, Accessibility Adaptations, PERS); Personal Supports (and Respite Care for under 21); Supported Living Coaching; Residential Services (Standard, Behavior Focused, Intensive Behavior); Support Coordination; Wellness and Therapeutic (Behavioral Services, Dietician, Nursing, Therapies, Counseling); Transportation; and Adult Dental Services.

Not all services are available in all settings. For instance Supported Living Coaching is a service intended to assist a client living in their own home, as opposed to their family home or a group home.

ICF: Intermediate Care Facility for individuals with intellectual or developmental disabilities (sometimes abbreviated as ICF/IDD). An ICF provides residential care through basic Medicaid for people needing that level of care and meeting the state’s definition of “developmental disability.” Some ICFs are large and operated by the State, and others are operated by private entities and range in size, including some that are as small as the group homes offered through iBudget. Because ICFs are a basic Medicaid service (like hospitalization or nursing home placement), there is no cap or waiting list.

Level of Care: Federal law requires that all enrollees in a Medicaid HCBS Waiver must meet an “institutional” level of care. For the LTC Waiver, the relevant institution is a nursing facility. For iBudget, it is an ICF.

• Nursing Facility Level of Care: The lowest level of care for a nursing facility - and the threshold for eligibility for the LTC Waiver - is Intermediate Level II. That level is described as “limited health related care and services required by an individual who is mildly incapacitated or ill to a degree to require medical supervision.” Examples of services someone at this level might need include help with mobility, transferring, dressing, grooming, bathing, meals (also known as “activities of daily living”) and services to relieve social isolation. Rule 59G-4.180(4)(c), Fla. Admin. Code

• ICF Level of Care: In addition to meeting the eligibility criteria for “developmental disability,” an iBudget applicant must have “severe functional limitations in at least three of the Major Life Activities.” (From the iBudget Waiver Application approved by CMS.) Major Life Activities include: self care, understanding and use of language, learning, mobility, self direction, and capacity for independent living.

LTC Program: Long-Term Care Program. The Medicaid managed care program for provision of nursing facility care and HCBS for adults. The full name is the Statewide Medicaid Managed Care (“SMMC”) Long-Term Care Program. 

LTC Waiver: Long-Term Care Waiver. The part of the LTC Program that is operated through managed care and provides HCBS from adults with disabilities or frail elders (65 and up) who would otherwise need a nursing facility level of care.  

LTC Waiver Priority Ranking: Priority for enrollment is generally determined by a screening for level of need or risk of nursing home placement. By statute, Florida exempts three categories of people from screening:

• Individuals who are 18, 19, or 20 and have a chronic debilitating disease or condition that generally requires 24/7 medical, nursing or health supervision or intervention.

• Nursing facility residents who have been in a Florida-licensed nursing facility at least 60 consecutive days.

• Individuals considered "high risk" by Adult Protective Services and placed in an assisted living facility temporarily with State funds.

If you are in an exempt category and you otherwise qualify for Medicaid, you may skip screening and seek to directly enroll. Otherwise, you must go through a screening on the phone that is used to give you a priority ranking of 1 - 8. The following priorities are set out by Rule 59G-4.193, Fla. Admin. Code: 

1. Score of 0-15 (not placed on waiting list)

2. Score of 16-29 (not placed on waiting list)

3. Score of 30-39 (on waiting list but unlikely to be released)

4. Score of 40-45 (on waiting list and slightly more likely to be released)

5. Score of 46 or more (likely to be released)

6. Aging Out Referral (must be referred by DCF)

7. Imminent Risk

8. Adult Protective Services High Risk Referral (must be referred by DCF)

The first 5 ranks are based on an algorithm linked to particular responses in the screening tool. Ranks 6 and 8, rarely used, are only available when an agency makes the referral. "Imminent Risk" applies when an individual living in their home or a community setting meets all of the following:

• Unable to perform self-care because of deteriorating mental or physical health condition(s).

• There is no capable caregiver.

• Placement in a nursing facility is likely within a month, or very likely within three months.

LTC Waiver Services: Every managed care plan must offer at least the following services, which are defined in the LTC Program Coverage Policy:

Adult Companion, Adult Day Care, Assistive Care Services, Assisted Living Facility Services, Attendant (Nursing) Care, Behavior Management, Caregiver Training, Case Management/Care Coordination, Home Accessibility Adaptation, Home Delivered Meals, Homemaker, Hospice, Intermittent and Skilled Nursing, Medical Equipment & Supplies, Medication Administration, Medication Management, Nursing Facility Care, Nutritional Assessment and Risk Reduction, Occupational/Physical/Speech/Respirator Therapies, Personal Care, Personal Emergency Response System, Respite Care, Transportation

LTC Supplemental Assessment: The LTC Program Coverage Policy states that along with the 701B comprehensive assessment, all MCPs are required to do a LTC Supplemental Assessment for each LTC Waiver enrollee. This assessment is intended to verify both how long the client can be left unsupervised and how many hours an unpaid “natural support” is willing and able to provide. The assessment should include the role of the natural support in the daily life of the enrollee, the natural support’s other responsibilities (like school, work, and care for others), the level of stress and any medical limitations in care of the enrollee, and the willingness to participate in the enrollee’s care. The MCP can factor in the care provided by natural supports when making its decision on services, but under its contract with AHCA to administer the LTC Waiver, only when those services are “agreed to and approved by the enrollee or the enrollee’s authorized representative.” Ex II-B, LTC Program, p.18, Oct. 2022.

MCP: Managed Care Plan. An entity (often a private health insurance company) contracted with AHCA to act as gatekeeper for Medicaid services and to deliver those services through its network of providers.  Plans are chosen (or assigned if you fail to chose) at initial enrollment and can be changed during annual open enrollment periods or for “cause.”

“Cause” for changing plans (with no need to get AHCA permission) including moving out of the plan’s service area, not being able to access a provider who is engaged in a continuing course of treatment, and a residential provider going from in-network to out of network. Other problems, like poor quality of care, lack of access to services or providers, and unreasonable delays in service require the enrollee to file a grievance with the plan unless there is immediate risk of permanent damage to health. Rule 59G-8.600, Fla. Admin. Code

Medical Necessity: No services or supports can be authorized unless they are “medically necessary.” This holds true for everything from prescription drugs to homemaker services. While it doesn’t make sense to think of homemaker services as a “medical” need, it may well be that without help with laundry, meals preparation, or a clean living space, the person won’t be healthy or safe in their home.  

Florida’s general definition of “medical necessity” or “medically necessary” is more clearly applicable to traditional medical or skilled services, requiring that the service:

·       Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain

·       Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs

·       Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational

·       Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide

·       Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider 

However, federal law requires a broader perspective for HCBS, including  taking into account what an enrollee needs to maintain functional capacity or to live and working in the setting of choice.

For almost all denials of HCBS, only two parts of the “medical necessity” definition are called into question: 1. that the service is “not in excess of the patient’s need,” and 2. that the service is “primarily intended for the convenience of … the recipient’s caretaker.”

Medicare: Federal health insurance for people aged 65 and older or disabled. Medicare is only available for people who have been employed and paid into the system, or their spouses, or the their minor or disabled adult children. 

MMA: Managed Medical Assistance. Basic Medicaid (hospitalization and outpatient care) administered by managed care plans. 

Natural Supports: For Medicaid HCBS purposes, this means unpaid supports provided voluntarily to a client in lieu of HCBS Waiver services.

NABD (LTC Waiver): Notice of Adverse Benefit Determination. The written notice issued by a managed care plan when denying, reducing or terminating services.

NPAR (LTC Waiver): Notice of Plan Appeal Resolution: The written notice issued by a managed care plan when an enrollee has appealed a NABD.  

PDO (LTC Waiver): Participant Directed Option. An option available for LTC Waiver enrollees that allows enrollees to hire and fire their own staff and use family members as paid staff, with certain restrictions.  

Plan of Care (LTC Waiver): Guided by the enrollee with the help of the care manager (and anyone the enrollee would like to be present), the Plan of Care should describe the enrollee’s goals, services and supports needed to meet those goals, authorized services (amount and duration) and how each service is funded. Enrollees should review and be provided a copy of the initial Plan of Care and any updates.

QSI (iBudget): Questionnaire for Situational Information. The comprehensive assessment tool used by APD to help determine the needs of persons with developmental disabilities.  

SMMC: Statewide Medicaid Managed Care. Florida’s name for the Medicaid programs that are administered by managed care plans. These include the programs for regular Medicaid (hospitalization and outpatient coverage) and Medicaid home and community-based services.  

State Plan Medicaid: also known as “basic,” “regular,” or “straight” Medicaid or MMA. The type of Medicaid that provides hospitalization, outpatient care and other services typically offered through private health care insurance. The “State Plan” is the extensive agreement between a state and the federal government on how this Medicaid program will be administered.  

Support Plan (iBudget): A plan for services and supports guided by the enrollee (or legal representative) and written by the WSC. The plan is based on the interests, goals and care needs of the enrollees.

Waiver Support Coordinator (WSC) (iBudget): Ongoing case management to ensure that an enrollee accesses services to maintain health, safety, and welfare. WSCs have the unenviable task of trying to make sure that enrollees access services and supports from any available funding source, not just iBudget. They also help find providers and monitor their care, keep all the many required forms and data updated, and are the liaison with APD for any requests for services.

701B (LTC Waiver): The comprehensive assessment tool used in the LTC Program to verify clinical eligibility and to help determine the needs of its participants. 

701S (LTC Waiver): A shortened version of the 701B used in determining waiting list priority for the LTC Waiver.