Frail and elderly Floridians whose disabilities require a nursing home level of care and who receive home and community based services (HCBS) through a Medicaid Managed Care Long-Term (LTC) plan have certain “rights” to direct their own care. This Know Your Rights Q & A provides some important information about this right.
Q. What is participant directed care?
A. During the care planning process, eligible enrollees can choose to “self-direct” certain services, including adult companion, homemaker, attendant care, intermittent and skilled nursing, and personal care. This is called the “participant directed option.” Participants who opt to self-direct these services are then responsible for training workers, setting work schedules and submitting time sheets. They do not set the pay rate.
Q. How do I know if I am eligible for the participant directed option?
A. Enrollees who live in their own home or the home of a family member are eligible.
Q. My sister, who is a nurse, has been providing my skilled nursing care through this program but she has had trouble getting paid on time and was told that she cannot be reimbursed for back pay. Is that correct?
A. NO. Your direct services workers are entitled to be fully reimbursed for the amount they are owed. You should request reimbursement from your plan.
Q. What should I do if my request for reimbursement for my sister is denied or delayed?
A. You should:
Q. Have there been any changes to the PDO due to COVID?
A. Yes. Under one of the emergency flexibilities provided to state HCBS programs due to the public health emergency, the Florida Medicaid Agency (AHCA) requested and received permission to add respite services and services for the provision of medication administration and management (if the direct service worker is qualified as an RN/LPN). These are in addition to the services listed above.
Q. How do I get more information or help regarding these rights?
A. This “Know Your Rights” Q & A is based on information in the Advocate’s Guide to the Florida Long-Term Care Waiver and in the consumer video for navigating the Florida Medicaid HCBS Program, prepared by the Florida Health Justice Project (FHJP).
While FHJP does not provide legal services or direct assistance to individuals, we do provide technical assistance to local legal services staff. You can find contact information for your local legal services office here.
If you are having difficulty getting needed HCBS services and want to “share your story,” you can contact the FHJP stories project here.
This material was prepared thanks to generous support from the RRF Foundation for Aging.
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The Florida Health Justice Project, a nonprofit organization, recognizes that access to quality and affordable health care is a human right and engages in comprehensive advocacy to expand healthcare access and promote health equity for vulnerable Floridians.
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