A proposed rule outlining how the poor, elderly and disabled will qualify for community-based services in a new Medicaid managed-care environment is getting a chilly review from some advocates, as well as the managed-care plans that will serve them.
The proposal — 59G-4.193 — lays out how the state will assign people to the statewide Medicaid-managed long-term-care program. The rule requires the Department of Elder Affairs to screen all applicants for the program using its tracking and referral system, which will automatically generate a placement order.
However, the rule exempts three categories of people from having to go through the screening process, allowing them to enter the long-term-care program immediately.
Those who can immediately be placed into the program without a DOEA screening include nursing facility residents who have lived in a nursing facility for 60 days; certain medically complex people, and individuals who have been referred by state Adult Protective Services for being at risk.
The language was not in the first iteration of the rule released in June but appeared in a version the Agency for Health Care Administration released in late October.
The Florida Association of Health Plans, among others, expressed concerns that the exemption violates the 2011 law that established the program. The law requires the DOEA to screen all individuals before they enter the program.
Exempting those categories of people and placing them directly in the program “may substantially change the case-mix of program participants in such a manner as to increase the severity of the disability in the program, thereby increasing costs to health plans beyond the rates that were negotiated ….,” Florida Association of Health Plans vice president and general counsel, Wences Troncoso, said in written comments he submitted to the agency.
AHCA even received written comments from the Agency for Persons with Disabilities. The agency wants to see criteria added to the screening process list to help individuals who are aging caregivers of individuals with developmental disabilities and those with Alzheimer’s Disease jump to the top of the wait list for services.
The brief meeting on the proposed rule was one of two Medicaid long-term- care managed meetings the agency held last week.
The other meeting the agency held was to discuss the capitation rates the health plans would be paid for providing services to those enrolled in the long- term-care program.