NEWS Trial on Medicaid Unwind Wraps Up

NEWS Trial on Medicaid Unwind Wraps Up

 FLORIDA’S LONG-TERM CARE ADVOCACY PROJECT

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

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)
  • Later Stages of Appeal
    • Redetermination
      • 42 C.F.R. §405.954-.958 (traditional Medicare)
    • Reconsideration by Qualified Independent Contractor (QIC)
      • 42 C.F.R. §405.960-.978 (traditional Medicare)
      • 42 C.F.R. §422.578-.422.596 (Medicare Advantage)
    • Right to a hearing (Administrative Law Judge)
      • 42 C.F.R. §405.1002-.1058 (traditional Medicare)
      • 42 C.F.R. §422.600, .602 (Medicare Advantage)
    • Medicare Appeals Council
      • 42 C.F.R. §405.1100-.1130 (traditional Medicare)
      • 42 C.F.R. §422.608 (Medicare Advantage)
    • Judicial review in Federal District Court
      • 42 C.F.R. §405.1136 (traditional Medicare)
      • 42 C.F.R. §422.612 (Medicare Advantage)

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.

Advocate Materials

DURABLE POWER OF ATTORNEY

ASSISTED LIVING FACILITIES

Statutes, Rules, and Regulations

Other Relevant Laws and Resources

Other State Best Practices: Minnesota

Comment Letter

NURSING HOME DISCHARGES

Statutes, Rules, and Regulations

Materials for Handling a Discharge

Materials for Advocates and Ombudsmen

Sample Discharge Final Orders

Consumer Handouts

Other Resources

Leave a Reply

Your email address will not be published. Required fields are marked *

Skip to content