Medicaid Resources - Florida Guardian ad Litem

Medicaid Resources and Links
Guardian ad Litem Trainings
Nancy E. Wright, Esq.
[email protected]
Medicaid Provider Handbooks
Handbooks You Will Probably Need to Access:
Behavioral Health Overlay Services (For Children under 21, based on contract with DCF,
Child Welfare and CBC organization)
Medical Foster Care
Specialized Therapeutic Services (Foster care and group homes, comprehensive
behavioral assessment for children determined by DCF to need out-of-home care or
sheltering OR in DJJ with emotional disturbance and at risk for residential placement)
Targeted Case Management Services For Children at Risk of Abuse and Neglect (Only
certain counties: Broward, Duval, Hillsborough, Martin, Dade, Palm Beach, Pinellas)
Under age 18, have parent request services, not getting TCM under another program,
meet certification criteria for risk of abuse/neglect)
Child Health Check-Up (formerly EPSDT) (Screenings and Immunizations)
Child Health Services Targeted Case Management (for Early Steps services to children
from birth to 3 and for services provided by CMS Medical Foster Care providers)
Community Behavioral Health Services (Most services available to all Medicaid
recipients, regardless of age)
Early Intervention Services (screenings, evaluations, individual or group sessions for
birth to 3 with developmental delay)
Home Health Services (allows for private duty nursing and personal care for children
under 21)
Therapy Services (notes that EPSDT allows for prior authorization of therapy services in
excess of limitations for children under 21)
Intermediate Care Facility for the Developmentally Disabled (This is NOT a waiver
service, but available to any Medicaid recipient who meets the eligibility criteria)
Provider General Handbook (includes section on “Medicaid Special Services for
Children that allows for prior authorization of a medically necessary service that is not
listed in a service-specific handbook. See pages 1-42 and 1-43.)
Developmental Disabilities Waiver Services
Traumatic Brain Injury and Spinal Cord Injury Waiver Services
Medicaid ABA (Applied Behavior Analysis) Provider List
Medicaid Eligibility
DCF Program Policy Manual Link:
Medicaid Due Process
42 USC 1396a(3) “A State Plan for medical assistance must … provide for granting an
opportunity for a fair hearing before the State agency to any individual whose claim for
medical assistance is denied or not acted upon with reasonable promptness.”
42 CFR 431.205 cites Goldberg v. Kelly, 397 US 254 (1970)
Recipient of public benefits is entitled to due process prior to withdrawal of benefits, i.e.:
 Timely, adequate notice
 Pre-termination evidentiary hearing
 Confront & cross-examine witnesses
 Present evidence & oral argument
 Impartial decision-maker
 Written decision
§409.285, Fla. Stat. Opportunity for hearing at DCF for denial, reduction or termination
of public assistance, or if application is not acted upon within a reasonable time.
Fair Hearing Authority
Administrative Procedures Act, Chapter 120
§120.569 Decisions which affect substantial interests
§120.57 Formal and informal hearing procedures
DCF Fair Hearing Rules: F.A.C. Rules 65-2.042-2.066
Uniform Rules of Procedure F.A.C. Chapter 28-106 Decisions Determining Substantial
Florida Rules of Civil Procedure
Template for Proposed Order:
Continuation of Medicaid Benefits
42 CFR §431.230 If the agency mails the required notice, and the recipient requests a
hearing before the date of action, the agency may not terminate or reduce services until a
decision is rendered after the hearing (with limited exceptions.)
42 C.F.R. §431.321 Services must be reinstated if the agency action is taken without
proper advance notification and the recipient requests a hearing.
42 CFR 438.420 Continuation of benefits while MCO appeal is pending IF
 Timely request for fair hearing (filed within 10 days of MCO notice of
 Termination, suspension, or reduction of a previously authorized course of
 Services were ordered by an authorized provider
 Original period covered by the original authorization has not expired; and
 The enrollee requests extension of benefits.
Corrective Action
42 C.F.R. §431.246 The agency must promptly make corrective payments, retroactive to
the date an incorrect action was taken, and if appropriate, provide for admission or
readmission of an individual to a facility if –
(a) The hearing decision is favorable to the applicant or recipient; or
(b) The agency decides in the applicant’s or recipient’s favor before the hearing.
FAC Rule 65-2.066(6) allows a DCF Hearing Officer to authorize retroactive corrective
French v DCF, 920 So. 2d 671 (Fla. 5th DCA 2006)
Kurnik v. HRS, 661 So. 2d 914 (Fla. 1st DCA 1995)
42 USC §1396d(r): EPSDT is defined to include:
(1) Screening Services (comprehensive health and developmental history, physical
exam, immunizations
(2) Vision services, including eyeglasses
(3) Dental services, including relief of pain and infections, restoration of teeth and
maintenance of dental health
(4) Hearing services, including hearing aids AND
(5) “Such other necessary health care, diagnostic services, treatment, and other
measures described in subsection (a) of this section [which lists all Medicaid
mandatory and optional services] to correct or ameliorate defects and physical and
mental illnesses and conditions discovered by the screening services, whether or not
such services are covered under the State plan.”
See also 42 C.F.R. §441.56
42 USC §1396d(a)(13): “Medical Assistance” includes “other diagnostic screening,
preventive and rehabilitative services, including medical or remedial services
recommended for the maximum reduction of physical or mental disability and restoration
of an individual to the best possible functional level.”
Garrido v Dudek, 731 F. 3d 1152 (11th Cir. 2013); K.G. v Dudek, 864 F. Supp. 1314
(S.D. FL 2012) (ABA services for children with ASD)
Smith v. Benson, 703 F. Supp. 2d 1262 (S.D. Fla. 2009) (Incontinence supplies)
Rosie D. v. Patrick, 410 F. Supp.2d 18 (D. Mass. 2006) (In-home behavioral supports)
Collins v. Hamilton, 349 F.3d 371 (7th Cir. 2003) (Long term residential psychiatric)
Pittman v. FL HRS, 998 F.2d 887 (11th Cir. 1993) (Organ transplant)
Pediatric Specialty Care, Inc. v. Ark. DHS, 293 F.3d 472 (8th Cir. 2002) (Early
intervention day treatment)
Moore ex rel Moore v Reese, 637 F.3d 1229 (11th Cir. 2011) (Medical necessity applies
to EPSDT, but to correct or ameliorate condition)
Medical Necessity
F.A.C. Rule 59G-1.010(166) “Medically necessary” or “medical necessity” means that
the medical or allied care, goods, or services furnished or ordered must:
(a) Meet the following conditions:
1. Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;
2. 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
3. Be consistent with generally accepted professional medical standards as
determined by the Medicaid program, and not experimental or investigational;
4. 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; and
5. Be furnished in a manner not primarily intended for the convenience of the
recipient, the recipient's caretaker, or the provider.
(b) “Medically necessary” or “medical necessity” for inpatient hospital services
requires that those services furnished in a hospital on an inpatient basis could not,
consistent with the provisions of appropriate medical care, be effectively furnished more
economically on an outpatient basis or in an inpatient facility of a different type.
(c) The fact that a provider has prescribed, recommended, or approved medical or
allied care, goods, or services does not, in itself, make such care, goods or services
medically necessary or a medical necessity or a covered service.
Administrative Finality
Peoples Gas System, Inc. v. Mason, 187 So. 2d 335 (Fla. 1966)
Felder v. Dept. of Mgmt Servs, 993 So. 2d 1031 (Fla. 1st DCA 2008)
Delray Medical v. AHCA, 5 So. 3rd 28 (Fla. 4th DCA 2009)
Agency Policy Changes
Courts v AHCA, 965 So. 2d 154 (Fla. 1st DCA 2007)
Brookwood-Walton County Convalescent Center v. AHCA, 845 So. 2d 223 (Fla. 1st
DCA 2003)
But see M.B. v APD, 13 So. 3d 509 (Fla. 3d DCA 2009) (Agency’s recent application
of detailed rule in existence during previous authorizations was not an impermissible
change in non-rule policy requiring adoption of a rule.)
Medicaid Managed Care
Federal Requirements
42 USC §1396u-2
42 C.F.R. Part 438 (Substantial revisions proposed June 2015. See link:
Managed Care Waiver Application with CMS
See link for copy of all Florida Waiver Applications:
State Requirements
Chapter 409, Parts III (Medicaid) and IV (Managed Care), Fla. Stat.
Medicaid Provider Handbooks
Medical Necessity Rule
Contract between MCO and AHCA:
Sunshine Health Child Welfare Member Handbook
Children’s Medical Service Network:
Magellan Complete Care:
AHCA Complaint Form: