Protecting Long-Term Care Residents’ Rights in Florida:

FLORIDA’S LONG-TERM CARE ADVOCACY PROJECT

RIGHTS TO MEDICALLY NECESSARY THERAPY (SPEECH, PHYSICAL, OCCUPATIONAL)

Jimmo v. Sebelius CMS Federal Website (including Important Message About the Jimmo Settlement; Settlement Agreement approved by Federal District Court in Vermont, Jan. 24, 2013; Fact Sheet; Medicare Manual Updates, Frequently Asked Questions)
“Discharge’ from a Skilled Nursing Facility: What Does it Mean and What Rights Does a Resident Have? (Center for Medicare Advocacy [CMA] Alert, Jan. 13, 2016) (discusses transfer and discharge rights of residents, as separate from, and in addition to, Medicare coverage and appeal rules)
Survey and Certification Issues Related to Liability Notices and Beneficiary Appeal Rights in Nursing Homes, Centers for Medicare & Medicaid Services [CMS], S&C-09-20 (Jan. 9, 2009) (describes expedited and standard appeals in traditional Medicare)

CMS Notices in Traditional Medicare

Overviews of Appeals

Appeal Regulations

Traditional Medicare
- Expedited appeal, 42 C.F.R. §405.1200-.1204
Medicare Advantage
- Request organizational determination
  - Request for service, 42 C.F.R. §422.568(b)
  - Request for payment, 42 C.F.R. §422.568(c)
  - When plan refuses to provide or pay for services, 42 C.F.R. §422.566(b)(3)

Residents Dually Eligible for Medicare and Medicaid

Florida Medicaid

At-a-Glance: Medicare and Medicaid: Dual Eligibles in Statewide Medicaid Managed Care (SMMC), Florida Agency for Health Care Administration (AHCA)
- Authorization Requirements: If a dual eligible requires a Medicare-covered service, the dual eligible must follow Medicare’s service authorization protocols. SMMC plans do not prior authorize services covered by Medicare.
- Medicare Crossover Claims: When there is a cost-sharing amount for a dual eligible, the Medicare system automatically transmits a ‘crossover’ claim to the Medicaid system for processing of the cost-sharing amount in accordance with SMMC contract requirements.
Fla. Admin. Code R. 59G-1.052, Third-Party Liability Requirements
Florida Medicaid Health Care Alert, AHCA (May 3, 2021)
- Effective July 1, 2021, skilled nursing facilities (and other specified providers) “must bill all services to a recipient’s D-SNP. The D-SNP is responsible for providing and/or arranging for Medicare and Medicaid benefits that a dually eligible individual is entitled to receive. Please note, a recipient can also be enrolled in a Medicaid Long-Term Care Plan, which is responsible for Medicaid long-term care services.”
- Alert also lists the D-SNPs in Florida.