Source: https://www.floridamedicaidguide.org/
Timestamp: 2019-04-19 15:07:02+00:00

Document:
Jazmine Janine Dykes | J.D.
We want to thank those who contributed, including the National Health Law Program (NHeLP). In addition to preparing The Advocates Guide to the Medicaid Program, a voluminous and essential resource for any health lawyer, Jane Perkins and Sarah Somers also provided a template for individual state guides. And Sarah not only generously shared her Advocate’s Guide to the North Carolina’s Medicaid Program (much of which appears in this document), she took time to review and edit this Guide.
We also want to thank Margaret Kosyk and Jazmine-Janine Dykes. Thanks are also due to Anne Swerlick, Florida Policy Institute, who has encyclopedic knowledge of Florida’s Medicaid Program, and Laurie Yadoff, Coast to Coast Legal Aid of South Florida, an expert in Florida's disability/Medicaid application process. They both took the time to answer questions and locate policies that are not easily available on line.
Medicaid is a complex and frequently changing federal-­state insurance program that covers medical expenses for eligible beneficiaries. Each state implements its own Medicaid plan in compliance with the federal Medicaid statute and regulations. While the federal statute and regulations prescribe the basic rules of the Medicaid program, states have significant flexibility and each state’s Medicaid program is unique.
When the Medicaid program was passed in 1965, coverage was limited to low-­‐ income individuals who qualified for either the “disability” related coverage (aged, blind, or disabled) or family related coverage (children, pregnant women, parents).
Shortly after passage of the ACA, Florida and other states sued the federal government alleging, inter alia, that this “Medicaid expansion” was unconstitutional. In National Federation of Independent Business v. Sebelius (NFIB), the Court upheld the ACA’s individual mandate as constitutional. The Court also ruled, however, that requiring states to expand their Medicaid programs to cover low income adults who did not meet a categorical connection was “overly coercive.”4 The Court’s decision meant that each state would decide whether or not to extend coverage to this group. As of April 2018, Florida is one of 19 states that has refused federal funding for coverage of the Medicaid expansion population.
Federal law requires each state to administer its Medicaid program through a single state agency. The designated state agency in Florida is the Agency for Health Care Administration (AHCA).
Under federal law, states must cover specified mandatory coverage groups, and states may cover additional categories who meet eligibility requirements.
Eligibility requirements include financial (income and resources) as well as technical requirements, e.g. citizenship and residency. Different financial eligibility limits and methodologies apply depending on whether the individual’s categorical connection to Medicaid is disability or family Related.
Florida's mandatory and optional coverage groups are set forth below.
Under federal law, states have the option of providing continuous eligibility for children even if the family income exceeds allowable limits over the course of the eligibility period.
Breast and Cervical Cancer Treatment (BCC).
The initial comment period to AHCA ended April 19, 2018. This Guide will be updated following the full comment period and a decision by CMS.
In Florida, the Department of Children and Families determines eligibility,51 and there should be “no wrong door” for applicants.
Individuals who are applying for Medicaid and Social Security Disability benefits, need to apply through a Social Security Administration office or the SSA website. SSI recipients will automatically be routed to the Division of Disability Determinations (DDS), which reviews applications for Medicaid.59 SSDI recipients whose income is too high for Medicaid will need to apply directly to DCF for Medically Needy.
Applicants for family related Medicaid, should apply online with DCF, rather than through the health care marketplace.
Generally, only information that is subject to change, such as income, household composition and disability, must be re-evaluated. Items that are not usually subject to change, such as citizenship and residence, need not be reevaluated unless a change has been reported.
Given the improved databases available post ACA, DCF is better able to perform the renewal based on information that is already available and make redeterminations of eligibility without requiring additional information from the beneficiary.
If DCF does not have the information needed in order to renew eligibility, they will send a notice to the individual giving at least 30 days to provide the necessary information. The preferred method for reporting changes is via the individual’s on-line My ACCESS Account. Individuals can report changes over the phone at the DCF statewide call center (866-762‐2237), by mail or in person.
· An individual’s SSI is and cancelled.
Eligibility disputes, unlike disputes over coverage of services, (see Section Five on Managed Care), are conducted at the DCF Office of Appeal Hearings pursuant to Florida Administrative Code Rules 65-­2.
Litigation has arisen when there is a difference of opinion between the state Medicaid agency and beneficiary(ies) over whether a specific service or item fits under one of those categories in 1396d(a).
These governing principles are discussed more fully below.
As discussed below, the Medicaid managed care regulations require access standards, thus providing advocates and beneficiaries with a basis thus for addressing service delays.
Individual states have significant flexibility in setting amount, duration and scope standards. Thus, for example, Florida has limited coverage for inpatient hospital stays to 45 days per year. This is a “reasonable" limit because it is sufficient in amount to cover the inpatient hospital needs of most adult beneficiaries.87 By contrast, Florida (and other states) cannot limit the coverage of services for recipients under 21, as long as the service is medically necessary for the individual child. Accordingly, the state rule for hospital services allows for coverage of medically necessary services of up to 365 days for recipients under age 21.
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a comprehensive set of benefits that is mandatory for children and youth under age 21 who are enrolled in Medicaid. EPSDT covers four separate types of screening services and includes immunizations, laboratory tests and health education. Each screen must be furnished at pre-set intervals and when a problem is suspected.
The treatment component of EPSDT includes any necessary health care, diagnostic services and other measures described in the Medicaid Act necessary to “correct or ameliorate” physical and mental conditions. Also required are outreach and informing, appointment scheduling and transportation assistance.
Screens, or well-child check-ups, are a basic element of the EPSDT program. As noted above, four separate types of screens are required: medical, vision, hearing, and dental.
Health education and anticipatory guidance.
EPSDT recipients are also entitled to periodic vision, hearing and dental examinations, as well as diagnosis and treatment for vision, hearing and dental problems.
Vision services must include vision screens and diagnosis and treatment of vision defects, including eyeglasses.
Hearing services must include hearing screens and diagnosis and treatment for defects in hearing, including hearing aids.
Dental services must include dental screens, relief of pain and infections, restoration of teeth, and maintenance of dental health.
That support services, specifically transportation and appointment scheduling assistance, are available on request.
If the child or family has difficulty reading or understanding English, then the information needs to be conveyed in a format that can be understood.
Florida was one of the first states to mandate enrollment in managed care plans. In 2006, the state received approval for a section 1115 Waiver96 that shifted Medicaid beneficiaries out of a fee-for-service delivery model (also referred to as “traditional” or “straight” Medicaid) into a managed care system.
The initial managed care program, which was known as “Medicaid Reform,” was piloted in five counties. After years of negotiations with the Center for Medicaid and Medicare Services (CMS), the State received permission to expand managed care statewide. The shift was completed in 2014, and most Florida Medicaid recipients are now enrolled in a program referred to as the Managed Medical Assistance Program (MMA).
Almost all Florida Medicaid recipients now receive their health care services through their MMA plan. Broadly speaking, the goal of managed care is to ensure better health outcomes with lower costs. Florida’s program is intended to improve the access standards that were available under traditional fee-for-service Medicaid. Additionally, managed care makes it easier to predict costs.
Because MMA plans control access to services for Medicaid beneficiaries, consumer advocates should be aware of the relevant authority governing Florida’s managed care program. For example, when assisting clients who may experience delays in receiving appointments, it is important to know the access standards prescribed in the managed care contract between the plans and AHCA.
As noted, most Medicaid recipients are required to receive their covered services through a managed care health plan.98 The voluntary enrollment population for MMA program, as well as the population excluded from the entire SMMC managed care program, are bulleted below.
Be given the opportunity to indicate a plan choice selection if they are prepared to do so.
If an individual is determined to be eligible for Medicaid and a health plan has not been selected during the application process, they will be enrolled into a plan through auto-assignment.
Through this process, also referred to as “ Express Enrollment, ” health plan enrollment will be effective the same day that the recipient’s eligibility application is approved.
Choice counselors are available for questions and advice on which plan best suits each recipient’s particular health care needs Choice counselors can be contacted at 1-877-711-3662. Recipients with special needs have the option of requesting an in-­person visit.
Recipients are encouraged to find a plan in which the individual’s doctors are in network in order to maintain continuity of care.
What services must be covered?
After enrollment into a health plan, recipients should receive a Member Handbook from their particular managed care provider detailing the services they are entitled to receive and information on how to contact the plan if a problem arises. The member handbook can also be found online or by calling the customer service representative for the particular plan.
Certain Medicaid services are not covered by MMA health plans, but are still available to eligible recipients through traditional fee-for-service Medicaid. Some important non-MMA services include Applied Behavioral Analysis (ABA), Early Intervention Services (EIS), and Medical Foster Care.
What access standards apply to the health plans?
Accordingly, “Network Adequacy Standards,” require all health plans to maintain a provider network that is “sufficient in numbers to meet the access standards for specific medical [and behavioral] services for all recipients enrolled in the plan” … in both urban and rural geographic areas.
For good cause, at any time.
Without cause, for voluntary enrollees at any time.
After 120 days, recipients may only change plans for “good cause.” After the 12-month period, recipients may change plans during the open enrollment period.
To change their plan, beneficiaries can speak with choice counselors, who are available to assist recipients in selecting a plan that best fits their needs.
A Florida Medicaid recipient enrolled in a statewide MMA plan may request to change managed care plans at any time for good cause reasons. Requests are made by phone to the choice counselor at 1-877-711-3662.
The enrollee does not live in a region where the Managed Care Plan (MCP) is authorized to provide services.
A substantiated marketing violation has occurred.
The enrollee is prevented from participating in the development of his/her treatment plan/plan of care.
The enrollee has an active relationship (has received services from the provider within the six months preceding the disenrollment request) with a provider who is not on the MCP’s panel but is on the panel of another MCP.
The enrollee is in the wrong MCP as determined by the Agency.
The MCP no longer participates in the region.
The state has imposed intermediate sanctions upon the MCP, as specified in 42 CFR § 438.702(a)(4).
The enrollee needs related services to be performed concurrently, but not all related services are available within the MCP network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk.
The MCP does not, because of moral or religious objections, cover the service the enrollee seeks.
The enrollee missed open enrollment due to a temporary loss of eligibility.
Enrollees who are having trouble accessing services or who are encountering other problems with their SMMC services can file an official complaint.
A complaint may be filed either online at https://apps.ahca.myflorida.com/smmc_cirts/ or by speaking with a Medicaid representative by calling toll free 1-877-254-1055 to speak to a Medicaid representative.
AHCA's online portal gives those filing a complaint the option to remain anonymous. However, if there is an issue that needs to be resolved, the person filing the complaint should provide their name and an email address or phone number.
First, under the Complainant Information section, the complainant must choose whether they are the Medicaid recipient or healthcare provider, or filing on behalf of the recipient or provider. The complainant can choose to either enter their name, email (if available), and phone number, or leave it blank.
Next, under the 'Who is the complaint/issue about?' section, the complainant will enter the recipient’s name, gold card, SSN, or Medicaid number, the county of residence, whether a previous complaint has been filed with AHCA, the type of managed care plan, the name of the managed care plan, and whether the complainant has contacted the plan.
Finally, under the 'Please complete all choices that relate to your issue' section, the complainant can indicate the type of complaint, e.g. having trouble obtaining a specific service.
This last section allows the complainant to describe in detail the issue and why a complaint is being filed.
What is the difference between a grievance and an appeal?
What is the Adverse Benefit Determination (ABD)?
In addition, ABDs include the denial of an enrollee’s request for an out of network service if the enrollee lives in a rural area and there is only one plan.
What is the time standard for filing a grievance or appeal?
Is there a statutory right to a fair hearing?
Under the federal Medicaid statute, Medicaid beneficiaries have the right to a fair hearing if a claim for medical assistance is denied or not acted on with reasonable promptness.
Is there a requirement that the plan appeal process be exhausted before filing a fair hearing?
Are there any exceptions to exhaustion requirement?
What time standards apply to various notices?
If the action concerns a termination, suspension, or reduction of a benefit - written notice must be sent 10 days before the date of action.
If the action concerns a denial of payment - notice must be sent at time of action affecting claim.
If the action concerns a standard service authorization decision that denies or limits services - notice must be sent within 14 days.
If an expedited service authorization has been requested - notice must be sent within 72 hours.
notice was not sent within 10 days of a termination, suspension or reduction of previously authorized benefits. (violates 42 C.F.R. § 438.404(c)(1)).
Is there a right to an expedited appeal?
Where to file fair hearings and who are the parties?
Pursuant to 2016 legislation, Medicaid appeals related to services for persons enrolled in a managed care plan and which are filed on or after March 1, 2017, are directed to AHCA. Fla. Stat. § 409.285(2).
How to ensure continuation of benefits pending appeal and state fair hearing if the ABD is a termination, reduction, or suspension of current services?
Suspension, or reduction of a previously authorized medical service, he or she has the right to receive continued coverage of the medical service pending the outcome of an appeal and fair hearing. The importance of the right to “aid pending” for low income individualized was recognized by the United States Supreme Court in the seminal case of Goldberg v. Kelly, 397 U.S. 254, 261 (1970).
What are enrollee rights in grievances and appeals?
Review medical records and case file free of charge and in advance.
Expedited appeals – file written appeal within 10 days of oral must be resolved within 72 hours.
Note: these time frames can be extended if the enrollee requests an extension. However, if the plan requests an extension, the plan must demonstrate to the state the need for additional time and why the extension would be in the best interests of the enrollee.
There are multiple authorities enumerated below which relate to Florida’s MMA program, including federal and state regulations (rules); Florida statutory provisions, contractual provisions between AHCA and the plans and the Special Terms and Conditions (STC) agreement between the state and federal government in the Section 1115 Waiver.
The federal Medicaid Managed Care regulations represent a significant development for Medicaid beneficiaries. After receiving voluminous comments from advocates, providers, and state governments, CMS issued final regulations in April 2016.
In 2011, the Florida Legislature created Part IV of Chapter 409, Florida Statutes directing the Agency to create the Statewide Medicaid Managed Care (SMMC) program. The SMMC program has two key components: the Managed Medical Assistance program (MMA) and the Long-Term Care program (not included in this Guide).
Attachment II, Exhibit II-A re: MMA Program, February 1, 2018, http://ahca.myflorida.com/Medicaid/statewide_mc/pdf/Contracts/2018-02-01/EXHIBIT_II-A_MMA_Managed_Medical_Assistance_(MMA)_Program_Feb_1_2018.pdf.
Under § 1115 of the Social Security Act, states can request authority to waive some, but not all portions of the Medicaid Act. The request is made to CMS through an 1115 Waiver request. CMS has discretion to approve or deny the waiver request, and if the Waiver is approved, the Special Terms and Conditions (also referred to as STCs) set forth the nature of CMS’ involvement and the state’s obligations throughout the waiver period.
The state’s relevant administrative rules pertaining to various covered medical services are found at Fla. Admin. Code Rule (or F.A.C.) 59G-4.010 et seq.
Also relevant is the state rule pertaining to plan disenrollment at F.A.C. 59G-8.600.
Finally, fair hearings related to Medicaid managed care are conducted by AHCA as described at 59G-1.100.
1 This document is intended to provide guidance on basic questions related to applications, eligibility, services, managed care and appeals. It does not address multiple components of the Medicaid program including, e.g. Institutional Care Medicaid, Home and Community Based Waivers, Medicare Savings Programs.
2 26 U.S.C. § 36B (c)(1)(A).
3 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII).
6 Centers for Medicare & Medicaid Services, CMS Regional Offices, (Mar. 20, 2018), https://www.cms.gov/About-CMS/Agency-Information/RegionalOffices/index.html.
7 Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the Children's Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2017 Through September 30, 2018, 81 FR 80078-0, https://www.gpo.gov/fdsys/pkg/FR-2016-11-15/pdf/2016-27424.pdf.
9 42 U.S.C. §1396a(a)(10)(A); 42 U.S.C. § 1396a(e)-(f); 42 C.F.R. §435.4; 42 C.F.R. Part 435, Subpart B; 42 C.F.R Part 435, Subpart C; See CMS, STATE MEDICAID MANUAL §§3300-3493, §§3500-3596; Fla. Stat. § 409.903; Fla. Stat. §409.904.
10 42 U.S.C. §1396a(a)(10)(C); 42 CFR 435.4; 42 CFR Part 435, Subpart D; See CMS, STATE MEDICAID MANUAL §§3600-3645.6; Fla. Stat. 409.904(2); Fla. Admin. Code 65A-1.703(6).
11 42 U.S.C. §1396a(a)(10)(A)(i), Fla. Stat. Fla. Stat. § 409.903,, Fla. Code Admin. Code 65A-1.703; Fla. Admin. Code 65A-1.710 .
12 Screening for Medicaid Eligibility Under the Pickle Amendment, http://povertylaw.org/clearinghouse/pickle.
13 42 U.S. Code § 1396b(v); 42 C.F.R. §435.406(b); 42 C.F.R. § 440.255; Fla. Stat. §§ 409.902(2)(b); 409.904(4); Fla. Admin. Code R. 65A-1.301(1); Fla. Admin. Code R. 65A-1.702(c); Fla. Admin. Code R. 59G-1.050(4).
14 42 U.S.C. §1396a(a)(10)(A)(ii); Fla. Stat. § 409.904; Fla. Admin. Code R. 65A-1.710.
NOTE: The income chart is accurate in terms of numeric income levels. However, the chart’s inclusion of two columns for different disregards: i.e. the “standard disregard” and the MAGI disregard” is not technically correct. Under the federal regulation, MAGI is only one disregard. The pre-ACA “standard disregard” was essentially incorporated into the eligibility standards when Florida and other states converted to MAGI and established new eligibility levels.
20 42 C.F.R. § 435.603(e); 26 U.S.C. § 36B(d)(2)(B); See 26 U.S. Code § 911 (citing exclusions which are added back in for MAGI under 26 U.S.C. § 36B(d)(2)(B)(i)). What to Include as Income, https://www.healthcare.gov/income-and-household-information/income/.
23 42 C.F.R. § 435.603(e).
25 As of the date of publication of this Guide, Florida has not yet amended the state administrative rules to conform to the federal regulation. Compare Fla. Admin. Code R. 65A-1.702, .703, .704, .705, .707, .708, .716 with 42 C.F.R §435.603(d)-(f).
26 Fla. Admin. Code R. 65A-1.710, see also SSI RELATED MEDICAID PROGRAMS FACT SHEET at 6-7, http://www.dcf.state.fl.us/programs/access/docs/ssifactsheet.pdf.
27 Fla. Admin. Code R. 65A-1.716(5)(a).
28 Fla. Admin. Code R. 65A-1.712.
29 Fla. Admin. Code R. 65A-1.712(1)(a); SSI-Related Programs - Financial Eligibility Standards: April 1, 2018, https://www.dcf.state.fl.us/programs/access/docs/esspolicymanual/a_09.pdf.
30 20 C.F.R. § 416.1201(a).
32 “Consider the resource value of a life insurance policy to be its cash surrender value (CSV), not its face value (FV).” SSA, POMS, SI 01130.300 C.1 (November 14, 2013).
33 “If an individual (claimant, recipient, or deemor) has legal authority to revoke or terminate the trust and then use the funds to meet his food or shelter needs, or if the individual can direct the use of the trust principal for his or her support and maintenance under the terms of the trust, the trust principal is a resource for SSI purposes. Additionally, if the individual can sell his or her beneficial interest in the trust, that interest is a resource.” SSA, POMS, SI 01120.200 D.1.a. (Dec. 11, 2013); This Guide is not addressing other resource related provision including e.g. special needs trusts.
34 20 C.F.R. § 416.1201(a)(1).
35 8 U.S.C. §1641(b); Fla. Stat. 409.902(2); DCF Policy Manual § 1430, § 1440.
36 8 U.S.C. § 1613(a); 42 C.F.R. § 435.406 (a)(2).
37 42 U.S.C. § 1396b(v)(2)‐(3); 42 C.F.R. § 435.406(b); 42 C.F.R. 440.255; Fla. Stat. § 409.902(2); Fla. Admin. Code R. 59G-­‐1.050(4).
39 8 U.S.C. § 1613(a); 8 U.S.C. § 1641; Fla. Stat. § 409.902(2).
Manual §1430.0300; DCF Policy Manual § 1440.0300.
the residency requirement. Residency is not contingent on the length of the stay. If the individual/household states an intent to return but has no plans to do so in the foreseeable future, they can be considered a resident of Florida. Residency does not exist if the evacuee states they are temporarily staying in Florida and have plans to return to Puerto Rico; and, therefore the individual/household is not eligible for Medicaid. All other financial and technical criteria must be met when determining eligibility for Medicaid."
435.910. Note: The federal regulation policy allows for an exception based on a “well established religious objection,” 42 C.F.R. § 435.910(h); the state rule allows for ”good cause “ failure to provide SSN Fla. Admin. Code R. 65A-1.302 (3); however the DCF program manual does not provide for any exceptions. See 1430.0200; 1430.0204.
46 42 U.S.C. § 1396d (r )(5); Fla. Admin. Code R. 65A-1.702(6).
47 Fla. Admin. Code R. 65A-1.702(5).
48 42 U.S. C. § 1396a(a)(34); 42 C.F.R. § 435.914, Fla. Admin. Code R. 65A-1.702(2)(9).
50 See, Schweiker v. Gray Panthers, 453 U.S. 34, 36-37 (1981).
53 42 C.F.R. §435.911(a)(1); Fla. Admin. Code R. 65A-1.205(1)(b).
54 Fla. Admin. Code R. 65A-­‐1.205, 42 U.S.C. §18083; 42 U.S.C. §1396w–3; Frequently Asked Questions, Department of Children and Families, http://www.myflfamilies.com/service-programs/access-florida/faq.
55 42 C.F.R. §435.911(a)(1); Fla. Admin. Code R. 65A-1.205(1)(b).
57 See, Pond v. Dep't of Health & Rehab. Servs. Dist. 7, (Fla. Dist. Ct. App. 1987(where "a caseworker is presented with specific and revealing information regarding the applicant's eligibility for benefits, that caseworker has an affirmative duty under 45 C.F.R. § 206.10(a)(2)(i) to inform that applicant at least orally of the conditions relevant to her eligibility.
58 See, Kurnik v. Department of Health and Rehabilitative Services, 661 So. 2d 914 (Fla. Dist. Ct. App. 1995)(holding that the Appellant’s right to apply for Medicaid and have her application processed in timely fashion was “inexplicably and inexcusably delayed” by the agency. The court stated that the appellant's "experience with that agency was characterized by no information, misinformation, unanswered letters, unreturned phone calls, unfulfilled promises, and classic bureaucratic runaround the sum total of which amounted almost to studied indifference if not purposeful neglect on the part of the agency."
60 Fla. Admin. Code R. 65A-1.205(1)(b).
61 Fla. Admin. Code R. 65A-2.042.
62 42 C.F.R. §435.541(c) (2)-(4).
64 Fla. Admin. Code Rule 65A-1.704(1); 42 CFR § 435. 916.
65 42 CFR § 435. 916.
69 U.S. CONST. amend .XIV, § 1; 42 U.S.C. §1396a(a) (3); 42 C.F.R. §§ 431.200-431.246; Fla.
Admin. Code R. 65-2; .Goldberg v. Kelly, 397 U.S. 254 (1970).
73 42. C.F.R. § 431.220 (b).
74 42 U.S.C. § 1396d(r)(5).
75 42 U.S.C. § 1396d(a).
77 As discussed in the Guide’s Section on Medicaid Managed Care, virtually all Florida Medicaid recipients are enrolled in a managed care organization (MCO). Thus, they receive their services through the MCO. The services both mandatory and options which are covered under Florida’s Managed care plan contracts are listed in the Appendix.
82 42 U.S. C §1396a(a)(10)(B)(i); 42 C.F.R. §§ 440.230(c), 440.240(b)(1).
83 K.G. ex rel. Garrido v. Dudek, 981 F. Supp. 2d 1275 (S.D. Fla. 2013), aff’d in part and modified in part, 731 F. 3d 1152 (11th Cir. 2013)(Court entered declaratory judgment finding that AHCA’s rule excluding coverage of any behavioral treatments for children with certain diagnoses, including autism violated Medicaid comparability requirements. Court of Appeals ordered that previously unpublished Declaratory Judgment, including ruling on comparability not addressed in the permanent injunction, be published. ).
85 42 C.F.R. § 1396a(a)(25)(C); 42 C.F.R. § 447.15, 447.20 ;Fla. Admin. Code R. 59G-1.050 (c)(8).
86 42 C.F.R. § 440.230.
88 Fla. Admin. Code R. 59G-­‐1.010, Definitions Policy, section 2.83 at 7.
89 42 U.S.C. § 1396d (r )(5)(1); AHCA’s website specifies the state’ s schedule for health checkups at the following website, which also specifies that Florida follows the Bright Futures/ American Academy of Pediatrics recommendations. http://ahca.myflorida.com/medicaid/childhealthservices/chc-up/index.shtml.
90 42 U.S.C. § 1396d (r )(2)-­‐(4); https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Periodicity-Schedule.aspx.
92 42 U.S.C. § 1396d (r )(5).
No time limits, like hourly or daily limits.
95 42 U.S.C. § 1396a(a)(43).
96 Sec. 1115 of the Social Security Act allows the Secretary of HHS to waive some requirements of the Medicaid Act so that states can test novel approaches to improving medical assistance for low-income people.
99 Fla. Stat. §409.972, AHCA Model Contract, Attachment II at 47-8, Section III. A. 2.
100 AHCA Model Contract, Attachment II at 47-8, at 48, Section III A. 3.
101 Services covered by MMA plans, See Appendix at 1.
102 See Fla. Admin. Code R at 59G-4.013-59G-4.330; AHCA Model Contract, Attachment II, Exhibit II-A at 9-51.
104 Model Contract, Attachment II, Exhibit II-A at 56-62.
110 42 C.F.R. § 438.400(b); Fla. Admin. Code 59G-1.100(2)(b) (definition of “adverse benefit determination”).
111 42 C.F.R. § 438.402(c)(2); Model Contract, SMMC, section IV, (C)(4)(a).
112 42 C.F.R. § 438.402; Fla. Admin. Code R. 59G-1.100 (3)(b)1; Model Contract, SMMC, at 86 Section IV, (C)(4)(a).
113 42 C.F.R. § 438.402 (c)(1)(A); 42 C.F.R. § 438.408(c)(3); Fla. Admin. Code R. 59G-1.100 (3)(b)2-3.
114 42 C.F.R § 438.10, Fla. Admin. Code R. 59G-1.100(2)(t); http://www.fdhc.state.fl.us/medicaid/statewide_mc/smmc_plan_comunications_archive.shtml, linking to a February 24 Policy Transmittal requiring that plans use a template notice. (available on the FLAdvocate Health Law website. https://www.fladvocate.org/healthandsenior/).
115 42 C.F.R. § 438.404(c).
116 42 C.F.R. § 438.410; Model Contract, Attachment II, Exhibit II Core Contract Provisions at 88, Section IV.C.5.m.
117 Model Contract, Attachment II, Exhibit II Core Contract Provisions at 87, Section IV, C. 5. B. (2); see also 42 C.F.R. § 438.406(b)(3).
118 42 C.F.R. § 438.406.
119 Model Contract, Attachment II, Exhibit II Core Contract Provisions, at 86, Section IV.C.4.b.; see also, 42 C.F.R. § 438.406 (b)(1).
120 Fla. Admin. Code R. 59G-1.100 (4).
121 Model Contract, Attachment II, Exhibit II Core Contract Provisions, at 91, Section IV. C.6.i.. 42 C.F.R. § 438.420.
122 Model Contract, Attachment II, Exhibit II Core Contract Provisions, at 91, Section IV. C.5.h; Section IV. C.6.k. see also 42 C.F.R. § 438.420(d).
123 42 C.F.R. § 438.406(b)(4)(5); compare Model Contract, Attachment II, Exhibit II Core Contract Provisions, Section IV.C. 5.d. at 87. (contract includes all of the provisions in federal regulation except the right to review of medical records and file free of charge).
124 Fla. Admin. Code R. 59G-1.100 (13).
125 Sample discovery is available on the FLAdvocate Health Law website. https://www.fladvocate.org/healthandsenior/.
126 Model Contract, Attachment II, Exhibit II Core Contract Provisions, Section IV C. 5,6; 42 C.F.R. 438.408.
127 See Appendix 2, AHCA chart of Filing and Resolving Time Frames.
128 42 C.F.R. § 438.408(e); Model Contract, Attachment II, Exhibit II Core Contract Provisions, at 89 Section IV. C. 6.n.

References: v. 
 § 438
 § 438
 § 409
 v. 
 § 1115
 § 36
 § 1396
 §1396
 § 1396
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