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Guest Blogger-Nancy Wright

Settlement Medicaid

Settlement Helps to Allow Medicaid Recipients to Avoid Institutionalization

Nancy Wright, a prominent Elder Law Attorney in Gainesville, was able to broker a settlement which helps to allow Medicaid recipients to avoid institutionalization.  Below are her comments about this important settlement.

After more than a year of litigation, the Florida Agency for Health Care Administration (AHCA) has settled with four Plaintiffs who challenged AHCA’s management of the Medicaid Long-Term Care (LTC) Program. As of December 1, 2016, this Program had more than 94,000 enrollees, all of whom are elderly or disabled. About half of the enrollees are in nursing homes, while the remaining half, like all of the Plaintiffs, have chosen to receive care in their homes or community rather than enter a nursing home. The Plaintiffs were represented by the Law Office of Nancy E. Wright (Lead Counsel), Disability Rights Florida, and Southern Legal Counsel.

Under the Settlement Agreement, health plans that administer Medicaid long-term care services will be “required to provide an array of home and community-based services that enable enrollees to live in the community and to avoid institutionalization.

The Settlement Agreement also states, among other things, that AHCA will

  • Adopt rules that set out requirements for coverage of long-term care services;
  • Require a new assessment procedure that takes into account the availability, willingness and ability of voluntary caregivers;
  • Amend their contract with health plans to assure compliance with these rules;
  • Require changes to health plan member handbooks to clarify enrollee rights and how to file consumer complaints;
  • Train (or retrain) health plans, hearing officers, AHCA staff and others on the new requirements;
  • Monitor case managers on how assessments are being done; and
  • Use enrollee surveys that ask about sufficiency of services.

The agreement impacts all six health plans now operating in Florida to provide Medicaid services through the Long-Term Care Program: Coventry/Aetna, Humana, Sunshine Health, Molina, United Healthcare, and Amerigroup.

1 Response

  1. Tammy DeCaro

    Jill, is there any discussion or legislative agenda to address the extremely low reimbursement to Assisted Living communities? The disparity between the ALF reimbursement and SNF reimbursement makes it difficult for Medicaid SMMC enrollees to remain in a home or community based setting.

    I find it appalling that a program that was designed to keep seniors in home or community based settings pays the highest amount to Skilled institutions vs. the community setting which often is the best placement.

    I have seen many seniors resort to the institutional setting simply because they cannot afford the alternatives. In my area, an ALF payment from Medicaid is $1100 for care only – it does not offset rent at all. Very few people can afford the ALF setting and end up in a SNF that receives about $7500 for that same person. How is this “good care” for the senior?

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