Assistive Care Services and Assisted Living for the Elderly Waiver

ASSISTIVE CARE SERVICES 

AND 

ASSISTED LIVING FOR THE 

ELDERLY WAIVER 

COVERAGE AND LIMITATIONS 

HANDBOOK

UPDATE LOG 

ASSISTIVE CARE SERVICES AND 

ASSISTED LIVING FOR THE ELDERLY WAIVER SERVICES 

COVERAGE AND LIMITATIONS HANDBOOK 

How to Use the Update Log 

Introduction 

Changes to the handbook will be sent out as handbook updates. An 

update can be a change, addition, or correction to policy. It may be 

either a pen and ink change to the existing handbook pages or 

replacement pages. 

It is very important that the provider read the updated material and file 

it in the handbook as it is the provider’s responsibility to follow correct 

policy to obtain Medicaid reimbursement. 

Explanation of the 

Update Log 

The provider can use the update log to determine if all handbook 

updates have been received. 

Update No. is the number that appears on the front of the update. 

Effective Date is the date that the update is effective. 

Instructions 

1. Make the pen and ink changes and file new or replacement pages. 

2. File the cover page and pen and ink instructions from the update in 

numerical order after the log. 

If an update is missed, write or call the Medicaid fiscal agent at the 

address given in Appendix C of the Medicaid Provider Reimbursement 

Handbook, HCFA-1500 and Child Health Check-Up 221 and the 

Medicaid Provider Reimbursement Handbook, Non-Institutional 081. 

UPDATE NO. 

EFFECTIVE DATE 

July 2001 New Handbook July 2001

ASSISTIVE CARE SERVICES AND 


Coverage and Limitations Handbook 

Table of Contents 

Chapter and Topic 

Page 

Introduction 

Handbook Use and Format ...........................................................................................ii 

Characteristics of the Handbook....................................................................................iii 

Handbook Updates.......................................................................................................iv 

Part I – Assistive Care Services 

Chapter 1 - Purpose, Background, and Program Specific Information 

Overview ......................................................................................................................1-1 

Description and Purpose ...............................................................................................1-2 

Provider Qualifications and Responsibilities ....................................................................1-4 


Chapter 2 - Covered Services, Limitations, and Exclusions 

Overview ......................................................................................................................2-1 

Requirements to Receive Services..................................................................................2-1 

Covered Service............................................................................................................2-5 

Assessments for ALF and AFCH Residents...................................................................2-6 

Service Plans for ALF and AFCH Residents..................................................................2-7 

Assessments for RTF Residents.....................................................................................2-11 

Treatment Plans for RTF Residents................................................................................2-13 

Leave of Absence and Discharge ...................................................................................2-14 

Termination of Services..................................................................................................2-15 


Chapter 3 - Procedure Codes and Fees 

Overview ......................................................................................................................3-1 

Reimbursement Information............................................................................................3-1 

Appendix A: Procedure Code Table and Fees ..............................................................A-1 

Appendix B: Appeal Rights and Fair Hearing Process....................................................B-1 

Appendix C: Certification of Medical Necessity Form...................................................C-1 

Appendix D: ACS Service Plan Form and Instructions ..................................................D-1

Appendix E: Resident Service Log and Instructions .......................................................E-1

Part II – Assisted Living for the Elderly Waiver Services 

Chapter 4 – Purpose, Background, and Program Specific Information 

Overview ......................................................................................................................4-1 

Description and Purpose................................................................................................4-1 

Provider Qualifications and Responsibilities ....................................................................4-2 


Chapter 5 - Covered Services, Limitations, and Exclusions 

Overview ......................................................................................................................5-1 

Requirements to Receive Services..................................................................................5-1 

Case Management Requirements ...................................................................................5-4 

Case Management Documentation.................................................................................5-5 

Plan of Care..................................................................................................................5-6 

Plan of Care Review and Reassessment .........................................................................5-9 

ALE Waiver and Assistive Care Covered Services.........................................................5-9 

Placement and Discharge ...............................................................................................5-17 

Termination of Services..................................................................................................5-18 


Chapter 6 – Procedure Codes and Fees 

Overview ......................................................................................................................6-1 

Reimbursement Information............................................................................................6-1 

Appendix F: Procedure Code Table and Fees...............................................................F-1 

Appendix G: Appeal Rights and Fair Hearing Process ...................................................G-1

Assistive Care Services and Assisted Living for the Elderly Waiver Services 


INTRODUCTION TO THE HANDBOOK 

Overview 

Introduction 

This chapter introduces the format used to prepare the Medicaid 

Reimbursement and Coverage and Limitations Handbooks and tells the 

reader how to use the handbooks. 

Background 

The Coverage and Limitations Handbook explains covered services, their 

limits and who is eligible to receive them. It is to be used with the 

Reimbursement Handbook, which describes how to complete and file claims 

for reimbursement by Medicaid. 

Legal Authority 

The Medicaid program is authorized by Title XIX of the Social Security Act 

and Title 42, Code of Federal Regulations. The Florida Medicaid program 

is authorized by Chapter 409, Florida Statutes (F.S.) and Chapter 59G, 

Florida Administrative Code (F.A.C.). 

Federal Regulations, Florida Statutes, and the Florida Administrative Code, 

which deal with the purpose, implementation, and administration of each 

Medicaid program, are cited for reference in each program Coverage and 

Limitations Handbook. 

In This Chapter 

This chapter contains: 

TOPIC 

Handbook Use and Format 

Characteristics of the Handbook 

Handbook Updates 

PAGE 

ii 

iii 

iv 

July 2001 

i



Handbook Use and Format 

Purpose 

The purpose of the Medicaid handbooks is to furnish the Medicaid provider 

with the policies and procedures needed to receive reimbursement for 

covered services provided to eligible Florida Medicaid recipients. 

The handbooks provide descriptions and instructions on how and when to 

complete forms, letters or other documentation. 

Provider 

The term provider is used to describe any entity, facility, person or group 

who is enrolled in the Medicaid program and renders services to Medicaid 

recipients and bills Medicaid for services. 

Recipient 

The term recipient is used to describe an individual who is eligible for 

Medicaid. 

Coverage and 

Limitations 

Handbook 

Each service handbook is named for the service it describes and is referred 

to as a “Coverage and Limitations Handbook.” A provider who furnishes 

more than one type of service will have more than one coverage and 

limitations handbook. 

Reimbursement 

Handbook 

Each reimbursement handbook is named for the claim form that it describes. 

A provider who bills on more than one type of claim form will have more 

than one reimbursement handbook. 

Chapter Numbering 

System 

The first page of each chapter designates the chapter number. The chapter 

number will appear as the first number of the page number at the bottom of 

each page in the handbook. 

Page Numbering 

Pages are numbered consecutively by chapter. Page numbers follow the 

chapter number found at the bottom of each page. 

July 2001 

ii



Handbook Use and Format, continued 

White Space 

The white space throughout a handbook is characteristic of the handbook 

format style. It enhances readability and allows space for writing notes 

during training and for on-the-job reference. 

Characteristics of the Handbook 

Format 

The format used in this handbook represents a concise and consistent way of 

displaying complex, technical material. 

Information Block 

One of the major features of the format is the information block, which 

replaces the traditional paragraph. Blocks are separated by horizontal lines. 

The block consists of one or more paragraphs or diagrams about a portion 

of a subject. Each block is identified or named with a label. 

Label 

Labels or names are located in the left margin of each information block. 

They describe the content or function of the block. 

Labels provide key subject matter identification which facilitates scanning 

and locating information quickly within a chapter or section within a chapter. 

Note 

Note: is used most frequently to refer the user to material located elsewhere 

in a handbook that is pertinent to the subject being addressed within the 

information block. 

Note: also refers the user to other documents or policies contained in other 

handbooks. 

July 2001 

iii



Characteristics of the Handbook , continued 

Topic Roster 

Each chapter contains a topic roster which lists the major subject areas 

covered in the chapter and gives the page number where the subject can be 

found. This topic roster serves as a table of contents for major sections 

within each chapter. 

Handbook Updates 

How Changes Are 

Updated 

The Medicaid handbooks will be updated as needed. 

Lengthy changes or multiple changes that occur at the same time will be sent 

on replacement pages. 

Brief changes will be sent as pen and ink updates. The pen and ink updates 

will be incorporated on replacement pages the next time replacement pages 

are produced. 

Update Log 

A page designated as the log will accompany handbook updates. This log 

serves as a reference for the provider to be sure that each update has been 

received. 

An “Update No.” will be indicated in the first column on the update log. The 

second column is titled the “Effective Date” and indicates the date that the 

update is effective. 

Numbering Update 

Pages 

Updated replacement pages will have the same number as the page they are 

replacing. If additional pages are required, the new pages will carry the 

same number as the proceeding replacement page with an alphabetic 

character in ascending order. 

July 2001 

iv



Handbook Updates, continued 

Effective Date of 

New Material 

The month and year that the new material is effective will appear in the 

bottom left corner of each page. The provider can check this date to ensure 

that the material being used is the most current and up to date. 

If an information block has an effective date that is different from the effective 

date on the bottom of the page, the effective date for the information block 

will be included in the label. 

Identifying New 

Information 

New material will be indicated by vertical, gray-shaded lines. The following 

information blocks give examples of how new labels, new information 

blocks, and new or changed material within an information block will be 

indicated. 

New Label 

A new label for an existing information block will be indicated by a vertical 

line to the left and right of the label only. 

New Label/New 

Information Block 

A new label and a new information block will be identified by a vertical line 

to the left of the label and to the right of the information block. 

New Material in an 

Existing Information 

Block 

New or changed material within an existing information block will be 

indicated by a vertical line to the left and right of the information block. 

New or Changed 

Paragraph 

A paragraph within an information block that has new or changed material 

will be indicated by a vertical line to the left and right of the paragraph. 

Paragraph with new material. 

July 2001 

v



This page intentionally left blank 

July 2001 

vi



Overview 

PART I 

CHAPTER 1 

ASSISTIVE CARE SERVICE 

PURPOSE, BACKGROUND, AND PROGRAM SPECIFIC INFORMATION 

Introduction 

This chapter describes Florida Medicaid’s Assistive Care Services program, 

specifies the authority regulating assistive care services, the purpose of the 

program, and provider qualifications and responsibilities. 

Information regarding Assistive Care Services covered by Florida Medicaid 

can be found on the Agency for Health Care Administration’s (AHCA) 

Internet site. The address is www.fdhc.state.fl.us, click on Medicaid, 

then click on Assistive Care Services. 


State plan Medicaid service programs, are authorized under Section 1902 of 

the Social Security Act and governed by Title 42, Code of Federal 

Regulations (C.F.R.), Part 440.167. 

The Florida Medicaid assistive care service is authorized by Chapter 409, 

Florida Statutes (F.S.) and the Florida Administrative Code (F.A.C.), 

Chapter 59G-4.025. and the handbook is incorporated in Chapter 59G- 

8.200. 



TOPIC 

PAGE 

Description and Purpose 1-2 

Provider Qualifications and Responsibilities 1-4 

July 2001 1-1



Description and Purpose 

Assistive Care 

Service Description 

The Assistive Care Services program is a Medicaid state plan service that 

provides care to eligible recipients requiring an integrated set of services on a 

24-hour per day basis. Eligible residents must reside in a qualified assisted 

living facility (ALF), adult family care home (AFCH) or residential treatment 

facility (RTF) and be provided scheduled and unscheduled care on a 24- 

hour per day basis when needed by the resident. 

Assistive care service recipients must demonstrate functional limitations that 

make it medically necessary for them to live in congregate living facilities and 

have access to integrated assistive care services on a 24-hour per day basis. 

Purpose 

The purpose of the Assistive Care Service program is to promote and 

maintain the health of eligible recipients and to minimize the effects of illness 

and disability in order to delay or prevent institutionalization. 

Medicaid 

Reimbursement 

This handbook is intended for use by ALFs, AFCHs and RTFs who provide 

assistive care services to eligible recipients. It must be used in conjunction 

with the Medicaid Provider Reimbursement Handbook, HCFA-1500 and 

Child Health Check-Up 221, which contains information about the 

Medicaid program in general, as well as specific procedures for submitting 

claims for payment. 

Personal Needs 

Allowance (PNA) 

All recipients of Assistive Care Services must be allowed to keep from their 

personal income an amount equal to the personal needs allowance under the 

Optional State Supplementation (OSS) Program. (Chapter 65A-2.036, 

F.A.C.) Currently the PNA is $54.00 per month. The PNA must be 

available to the resident by the tenth day of each month. The facility may 

assist the resident in managing these personal funds, but may not restrict how 

the resident chooses to spend the PNA funds. 

July 2001 1-2



Description and Purpose, continued 

Medicaid Fraud and 

Abuse 

Consult Chapter 5 of the Medicaid Provider Reimbursement Handbook 

HCFA 1500 and Child Health Check-Up 221, for information regarding 

Medicaid policy on provider abuse and fraud and Medicaid’s recoupment 

policies. 

Administrative 

Responsibility 

The assistive care service program is jointly administered by the Agency for 

Health Care Administration (AHCA), and the Department of Children and 

Families (DCF). 

• AHCA is responsible for assuring compliance with federal program 

requirements, developing Medicaid policy, program operations, and for 

reimbursing Medicaid providers. 

• DCF is responsible for determining the recipient’s OSS and Medicaid 

eligibility. 

Area Medicaid 

Offices 

Area Medicaid offices are located throughout Florida to assist Medicaid 

service providers with questions and problems. 

Note: See Appendix C of the Medicaid Provider Reimbursement 

Handbook, HCFA-1500 and Child Health Check-Up 221, for a list of 

area Medicaid office addresses and telephone numbers. 

July 2001 1-3



Provider Qualifications and Responsibilities 

General Assistive 

Care Service 

Provider 

Qualifications 

Three types of residences may qualify as Medicaid Assistive Care Service 

providers: 

• Assisted living facilities (ALFs) licensed pursuant to Chapter 400, Part 

III, FS; 

• Adult family care homes (AFCHs) licensed pursuant to Chapter 400, 

Part VII, FS; and 

• Mental Health Residential treatment (RTFs) facilities licensed pursuant to 

Section 394.875 FS. 

In addition, an ACS provider must meet the following qualifications: 

• Is not an institution for mental diseases (IMD) as defined in 

42 CFR § 435.1009(2); 

• Provide on-site care to residents seven days a week; 

• Does not have a contract with a state agency that provides 

reimbursement for assistive care services as defined in this 

handbook; 

• Will not claim reimbursement for assistive care services for any 

recipient receiving a payment for personal care through the Optional 

State Supplementation (OSS) Program under Chapter 409.212, FS. 

Special Assistive 

Care Provider 

Requirements for 

RTFs 

Along with their Medicaid Provider application, RTFs must submit two 

additional forms: 

• Provider Self-Certification Form (AHCA From 5000-3200) and 

• Roster of OSS recipients. 

July 2001 1-4



Provider Qualifications and Responsibilities, continued 

ALF Facility 

Administrators 


ALF facility administrators and managers must: 

• Satisfy requirements of Chapter 400.425, F.S. and the training 

requirements of Chapter 58A-5.019, F.A.C. 

Documentation of these qualifications must be maintained in the facility 

personnel files and must be made available to AHCA monitoring staff or its 

designees upon request. 

ALF Direct 

Care Staff 


ALF direct care staff must have the following qualifications: 

• Satisfy the qualifications for ALF Direct Care Staff in Chapter 58A- 

5.019, F.A.C. and the training requirements of Chapter 58A-5.0191, 

F.A.C., and; 

• Documentation delegating the authority to sign ACS service plans to 

ALF Direct Care Staff, if the administrator does not perform this 

function. 

Documentation of these qualifications must be maintained in the staff 

member’s personnel file at the facility and must be made available to AHCA 

monitoring staff and surveyor staff upon request. 

Adult Family 

Care Home 

(AFCH) Provider, 

Relief Person and 

Staff Qualifications 

AFCH providers, relief persons and staff must satisfy the following 

qualifications: 

• Satisfy the requirements of Chapter 400.621, F.S. and 

Chapter 58A-14.008, F.A.C. 


personnel records and be made available to AHCA monitoring or surveyor 

staff upon request. 

July 2001 1-5




RTF Manager 

and Staff 


All RTF managers and staff must have at least the following qualifications: 

• Comply with Chapter 394, F.S. and Chapter 65E-4.019, F.A.C.; and 

• Documentation delegating the authority to sign ACS service plans to 

RTF Direct Care Staff, if the RTF manager does not perform this 

function. 


personnel records and be made available to AHCA monitoring or surveyor 

staff upon request. 


Provider 

Responsibilities 

The assistive care provider has the responsibility to: 

1. Αssist prospective ACS applicants with applications for Medicaid 

services, if they have not already been determined eligible for Medicaid; 

2. Advise the ACS applicant and recipient of their fair hearing rights and the 

grievance process; 

3. Arrange for health assessments annually or when significant changes 

occur in an ACS resident’s condition; 

4. Develop and implement a service plan for each recipient; 

5. Document that the recipient is receiving services from the facility staff on 

each day for which ACS is billed; 

6. Maintain up-to-date recipient case records in accordance with the 

handbook and applicable licensure requirements; 

7. Coordinate other services provided to the consumer, such as hospice, 

waiver, and Medicare (including providing copies of the resident contract 

to the waiver case manager or hospice coordinator in order to 

coordinate the service plan and avoid service duplication); 

July 2001 1-6





Provider 

Responsibilities, 

continued 

8. Provide an integrated set of services on a 24-hour basis; 

9. Provide all ACS recipients with a personal needs allowance (PNA) in an 

amount equal to that set by Chapter 65A-2.036, F.A.C.; 

10. Comply with all provisions of the Medicaid Provider Agreement; 

11. Cooperate with Medicaid monitoring staff or its designated 

representatives; 

12. Comply with all licensure requirements applicable to the facility; and 

13. Comply with the requirements of Rule 59G-8.200 (15), F. A. C. and the 

Assistive Care Services and Assisted Living for the Elderly Coverage 

and Limitations Handbook. 

July 2001 1-7

Assistive Care Services and Assisted Living for the Elderly Wavier Services 


Overview 

PART I 

CHAPTER 2 


COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS 

Introduction 

This chapter describes the services covered under the Florida Medicaid 

Assistive Care Service (ACS) program. It also describes the requirements 

for service provision, service limitations, and exclusions. 



TOPIC 

PAGE 

Requirements To Receive Services 2-1 

Covered Service 2-5 

Assessments for ALF and AFCH Residents 2-6 

Service Plans for ALF and AFCH Residents 2-7 

Assessments for RTF Residents 2-11 

Treatment Plans for RTF Residents 2-13 

Leave of Absence and Discharge 2-14 

Termination of Services 2-15 

Requirements to Receive Services 

Introduction 

Medicaid may reimburse for assistive care services provided in qualified 

Assisted Living Facilities (ALFs), Adult Family Care Homes (AFCHs), and 

Residential Treatment Facilities (RTFs) to eligible Medicaid recipients. 

July 2001 2-1

Assistive Care Service and Assisted Living for the Elderly Wavier Services 


Requirements to Receive Services, continued 

Medicaid 

Application 


If an individual has not applied for and been determined eligible for Medicaid 

at the time Assistive Care Services (ACS) are needed, the individual must 

submit a Request for Assistance (RFA) to the local service center of the 

Department of Children and Families. Providers should assist individuals with 

this process. 

Note: See Appendix C of the Medicaid Provider Reimbursement 

Handbook, HCFA-1500 and Child Health Check-Up 221 for a list of the 

DCF district offices. A map of district offices is available on the Internet at 

www.MyFlorida.com. Click on Directory, and then click on Children and 

Families, then click on Economic Services, and then click on Service Center 

of desired county. 

Who Can Receive 

ACS Services 

To receive assistive care services, recipients in this program must be at least 

18 years of age or older and meet the following requirements: 

1. Be Medicaid eligible; 

2. Have a health assessment completed by a physician or other licensed 

practitioner of the healing arts acting within the scope of their practice 

under state law which indicates the medical necessity of assistive care 

services; 

3. Be determined to need at least two service components of the 

assistive care service; 

4. Reside in an ACS-enrolled ALF, RTF, or AFCH; and 

5. Not participate in any Medicaid managed care program such as the 

Eldercare HMO, or the Long-Term Care Community Pilot Project 

where the capitated payment is designed to cover all Medicaid 

services. 

Assisted Living for the Elderly (ALE) waiver recipients can receive ASC 

services provided the waiver and ACS component services are not 

duplicative and appear on the ALE service plans. 

Note: See Part II of this handbook for information on the ALE waiver 

program requirements. 

July 2001 2-2




Who Cannot 

Receive ACS 

Services 

Institutionalized Medicaid recipients residing in institutions such as nursing 

facilities, state mental hospitals, institutions of mental disease, or intermediate 

facilities for the developmentally disabled cannot receive ACS. 

Income Guidelines 

for Assistive Care 

Service (ACS) 

The income guidelines for facilities with potential assistive care service 

residents are as follows: 

Applicants Maximum Income for: Amount: 

OSS recipient 

$609.40 per month 

Medicaid (MEDS-AD) (unless eligible for $665.00 per month 

Medicaid under ICP or Medicaid Waiver) 

Home and Community-Based Waiver $1,593.00 per month (ICP 

income limit) 

Residents with monthly incomes at or below $609.40 are eligible for both 

OSS and ACS payments. 

Residents with monthly incomes between $609.41 and $665.00 can receive 

ACS provided other Medicaid eligibility requirements are met. 

Residents with monthly incomes between $665.01 and $1,593.00 are not 

eligible for ACS alone. These residents may be eligible for ACS through the 

ALE waiver as described in Part II of this handbook. 

If an individual is eligible for Medicaid through the Medically Needy Program, 

he or she is not eligible for ACS. 

Note: Income limits are revised as federal poverty levels are updated. 

Please check the SSI-Related Fact Sheet on the Internet at 

www.fdhc.state.fl.us for the latest updates. Click on Medicaid. There is a 

link to the SSI-Related Fact Sheet on the Medicaid page. Information about 

income limits is also available from the DCF service centers. 

July 2001 2-3




Functional and 

Health Criteria 

Eligible Medicaid recipients must have at least the following functional 

capabilities: 

• Ambulatory, with or without assistance; 

• Does not exhibit chronic inappropriate behavior which disrupts the 

facility’s operations or is harmful to self or others; 

• Is capable of taking his or her medication with assistance; 

• Does not have any stage 3 or 4 pressure sores; and 

• Does not require 24-hour nursing supervision. 

Definition of 

Medical Necessity 

Chapter 59G-1.010, F.A.C., defines medical necessity as medical or allied 

care, or services furnished or ordered that must: 

• Be necessary to protect life, to prevent significant illness or significant 

disability, or to alleviate severe pain; 

• Be individualized, specific, and consistent with symptoms or confirmed 

diagnosis of the illness or injury under treatment, and not in excess of the 

patient’s needs; 

• Be consistent with generally accepted professional medical standards as 

determined by the Medicaid program, and not experimental or 

investigational; 

• Be reflective of the level of service that can be safely furnished and for 

which no equally effective and more conservative or less costly treatment 

is available; and 

• Be furnished in a manner not primarily intended for the convenience of the 

recipient, the recipient’s caregiver, or the provider. 

Need for Assistive 

Care Services 

A recipient of ACS must require an integrated set of services on a 24-hour 

basis and must have a health assessment establishing the medical necessity of 

at least two of the four service components described below. 

July 2001 2-4



Covered Service 



W-9659 

Assistive care services are an array of services provided on a daily basis by 

or through ALFs, AFCHs, or RTFs. 

The following components may be included in the assistive care service plan: 

• Health support; 

• Assistance with activities of daily living (ADLs); 

• Assistance with instrumental activities of daily living (IADLs); and 

• Assistance with self-administration of medication. 

The criteria for provision of each component are explained below. 

Health Support 

Component 

Health support is defined as requiring the provider to: 

• Observe the recipient’s whereabouts and well-being on a daily basis; 

• Remind the recipient of any important tasks on a daily basis; and 

• Record and report any significant changes in the recipient’s appearance, 

behavior, or state of health to the recipient’s health care provider, 

designated representative, or case manager. 

Assistance with 

Activities of Daily 

Living (ADLs) 

Component 

Assistance with activities of daily living (ADLs) is defined as providing 

assistance with one or more of the following activities: individual assistance 

with ambulating, transferring, bathing, dressing, eating, grooming, and 

toileting. At least one service component must be required daily. 

July 2001 2-5



Covered Service, continued 


Instrumental Acts of 

Daily Living 

(IADLs) 

Component 

Assistance with instrumental activities of daily living (IADLs) is defined as 

providing intensive assistance with one or more of the following activities: 

individual assistance with shopping for personal items, making telephone calls, 

and managing money 


Self-Administration 

of Medication 

Component 

Assistance with self-administration of medication is defined assistance with or 

supervision of self-administration of medication at least daily in accordance 

with licensure requirements applicable to the facility type. 

Implementation of 



Assistive care services for an eligible recipient may be provided and billed 

from the first day of need for services as long as service planning is under way 

and completed as required. 

Assessments for ALF and AFCH Residents 

Initial Health 

Assessment 

If the need and eligibility for ACS commence with admission to the ALF and 

AFCH, the initial assessment requirement is the same as for the facility type. 

• ALF Residents 

• AFCH Residents 

Chapter 58A-5.0181 (2), F.A.C. 

Chapter 58A-14.0061, F.A.C. 

If the need and eligibility for ACS commence after admission to the ALF and 

AFCH, an assessment following the same procedure as for re-assessment 

must be completed prior to billing for ACS. 

However, if the admission does not document the need for at least two of the 

four ACS components, additional documentation must be obtained from the 

health care provider. The optional Certification of Medical Necessity form 

may be used for this purpose. 

Note: See Part I, Appendix C for a copy of the form and instructions. 

July 2001 2-6



Assessments for ALF and AFCH Residents, continued 

Re-Assessment 

Recipients receiving Assistive Care Services must have a complete 

assessment at least annually or sooner if a significant change in the recipient’s 

condition occurs. An annual assessment must be completed no more than 

one-year plus fifteen days after the last assessment. An assessment triggered 

by a significant change must be completed no more than fifteen days after the 

significant change. The assessment must be completed by physician or 

physician assistant or advanced registered practitioner. The assessment must 

document the need for at least two of the four Assistive Care Service 

components. 

Note: Either the DOEA Form 1823 for ALF residents, the DOEA Form 

1110 for AFCH residents or the optional Certification of Medical Necessity 

form in Appendix C must be used for this purpose. 

Significant Change 

Chapter 58A-5.0131, F.A.C., defines significant change as a sudden or 

major shift in behavior or mood, or deterioration in health status such as 

unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure 

sore. Ordinary day-to day fluctuations in functioning and behavior, a shortterm 

illness such as a cold, or the gradual deterioration in the ability to carry 

out the activities of daily living that accompanies the aging process are not 

considered significant changes. 

Service Plans for ALF and AFCH Residents 

Service Plans 

Every ACS recipient must have a service plan completed by the ACS service 

provider. The ALF or AFCH is responsible for insuring the service plan is 

developed and implemented. 

July 2001 2-7



Service Plans for ALF and AFCH Residents, continued 

Service Plans, 

continued 

Service plan development involves six principles: 

• Individuality—addresses individual needs and preferences; 

• Accountability—specifies who is responsible for providing service; 

• Outcome orientation—identifies outcome of service; 

• Completeness—addresses all needs in the health assessment; 

• Input—resident must be consulted and agree with the plan; and 

• Staffing—guides staffing and facilities. 

Required 

Components 

The service plan must be completed within 15 days after the initial health 

assessment or reassessment, be in writing, and based on information 

contained in the health assessment. The service plan must include: 

• Ιdentifying information (facility name, resident’s name, Medicaid 

identification number, and date); 

• Services that address all needs identified in the health assessment; 

• Level of functioning and assistance needed; 

• Service provider; 

• Expected outcome of service; 

• Signed and dated by facility representative and resident, guardian or 

designated representative; and 

• Updates when conditions change. 

All needed ACS components must be specified in the recipient’s service plan. 

July 2001 2-8




Acceptable Formats 

Providers may use the optional form in Part I, Appendix D for documentation 

of the service plans. 

Provided the Service Plans contain the required components other acceptable 

formats are: 

• Community Living Support Plan, 

• Medicaid Waiver Service Plan, 

• Extended Congregate Care (ECC) Service Plan, and 

• Provider’s Service Plan form with required components. 

Note: Instructions for the optional form are in Part I, Appendix D. 

Service Plan 

Approval 

The service plan must be completed no more than 15 days after the most 

recent health assessment. 

Service plan approval requires two signatures. For an ALF, the facility 

administrator or person designated in writing by the administrator must sign. 

For an AFCH, the provider who is the licensee must sign the service plan. 

The service plan must also be signed by the resident except: 

• If the resident has a legal guardian, the guardian must sign the form on the 

resident’s behalf. 

• If the resident has a representative designated in writing, the 

representative may sign the form on the resident’s behalf. 

The service plan is considered complete as of the last date signed by either 

party. 

July 2001 2-9




Service 

Documentation 

The ALF or AFCH must document that recipients received services in the 

facility on each day for which ACS is billed. There is no required format for 

such documentation. 

Note: See Part I, Appendix E for the Optional Service Plan Log Form that 

can be used for this purpose. 

Service Plan Review 

The service plan must be reviewed and updated to reflect the current needs 

of the recipient. The service provider must monitor the service plan for 

continuity of services and determine if changes in the recipient’s status 

warrant changes in the service plan. 

New Service Plan 

A new service plan is required on an annual basis or sooner if a significant 

change in the recipient’s condition occurs. The new service plan must be 

completed no more than 15 days after the re-assessment required above. 

ACS Records 

In addition to records required by the applicable licensure standards, ACS 

records that must be kept include: 

• Copies of all eligibility documents, ( i.e., DCF OSS Notice of Case 

Action, or Medifax strip) 

• Health Assessment Forms (DOEA Form 1823 or 1110) and 

reassessments forms; 

• Assistive care service plan with updates, if any; and 

• Copy of daily roster or other daily service documentation. 

This documentation must be maintained at the facility, kept for at least five 

years and be made available to Medicaid staff or its designated representative 

upon request. 

Note: See Chapter 2 of the Medicaid Provider Reimbursement 

Handbook, HCFA 1500 and Child Health Check-Up 221, for additional 

information about documentation requirements. 

July 2001 2-10




ACS Record 

Documentation 

ACS documentation must be in ink and must be legible. No erasures or 

white out are permitted. In case of an error, the ALF administrator or 

designee, or AFCH provider must line through the error, initial and date it, 

then make the correct entry. 

Service Plan 

Approval Impasse 

and Fair Hearing 

Rights 

If the either the recipient, guardian or representative does not agree with the 

service plan, and resolution cannot be reached, the service provider must 

provide the recipient with instructions on the fair hearing process and assist 

the recipient with preparing for the fair hearing. If the service provider has 

any in-house grievance process, the recipient’s rights to a fair hearing cannot 

be replaced by the in-house grievance process. 

Note: See Part I, Chapter 3, Appendix B of this handbook for fair hearing 

process information. 

Assessments for RTF Residents 

Initial Assessment 

If the need and eligibility for ACS commence with admission to the RTF, the 

initial assessment completed pursuant to Chapter 65E-4.016(9), F.A.C., 

meets the assessment requirement for ACS. 

If the need and eligibility for ACS commence after admission to the RTF, an 

assessment following the same procedure as for re-assessment must be 

completed prior to billing for ACS. 

July 2001 2-11



Assessments for RTF Residents, continued 

Re-Assessment 

Recipients receiving Assistive Care Services must have a complete 

assessment at least annually or sooner if a significant change in the recipient’s 

condition occurs. An annual assessment must be completed no more than 

one-year plus fifteen days after the last assessment. An assessment triggered 

by a significant change must be completed no more than fifteen days after the 

significant change. The assessment must be completed by physician or 

licensed mental health professional. The assessment must document the need 

for at least two of the four Assistive Care Service components. 

Note: See Part I, Appendix C for the optional Certification of Medical 

Necessity form that may be used for this purpose. 


Chapter 58A-5.0131, F.A.C., defines significant change as a sudden or 

major shift in behavior or mood, or deterioration in health status such as 

unplanned weight change, stroke, heart condition, or stage 2, 3, or 4 pressure 

sore. Ordinary day-to day fluctuations in functioning and behavior, a shortterm 

illness such as a cold, or the gradual deterioration in the ability to carry 

out the activities of daily living that accompanies the aging process are not 

considered significant changes. 

July 2001 2-12



Treatment Plans for RTF Residents 

Treatment Plans for 

RTF residents 

Every ACS recipient must have a treatment plan completed, implemented and 

reviewed according to the requirements of Chapter 65E-4.016(11), F.A.C. 

Assistive care services for an eligible recipient may be provided and billed 

from the first day of need for services as long as treatment planning is under 

way and completed as required. 

Service 

Documentation for 

RTF Residents 

The RTF must document that residents received ACS on the day billed. 

There is no required format for such documentation. 

ACS Records 

In addition to the records required by Chapter 65E-4.016 (11), F.A.C., 

ACS records must be kept for every recipient receiving ACS. ACS records 

must include copies of all eligibility documents, i.e., OSS Notice of Case 

Action or a copy of the Medifax strip. 

Documentation applicable to ACS must be kept for at least five years and be 

made available to Medicaid staff or its designated representatives upon 

request. 


Handbook, HCFA 1500 and Child Health Check-Up 221, for additional 

information about documentation requirements. 

July 2001 2-13



Leave of Absence and Discharge 

Introduction 

Medicaid recipients must reside in an ACS-enrolled facility in order to 

receive ACS services. A recipient that is not a resident of an ACS-enrolled 

facility will be denied ACS services even if all other eligibility criteria are met. 

A recipient may be terminated from ACS, under some circumstances, when 

moving from one facility to another. Recipients must be advised of their rights 

to appeal these actions when they occur. 



Leave of Absence 

Recipients may leave the facility for more than 24 hours from time to time for 

health or personal reasons. During such periods, Assistive Care Services are 

not being provided and may not be billed. 

ACS Discharge 

Requirements 

If the ALF, AFCH, or RTF representative initiates discharge of an ACS 

recipient, the discharge must be done in accordance with the licensure 

requirements applicable to the facility type. 

Move to Another 

ACS Provider 

If the recipient requests to move or is moved from one ACS-enrolled facility 

to another ACS-enrolled facility, the discharging facility representative will 

assist in coordinating the placement, and the recipient will remain eligible to 

receive ACS in the new facility. 

The discharging facility may not bill for the day of discharge. The admitting 

facility may bill for the day of admission. 

Any time a change in facility is necessary for a recipient who receives 

Optional State Supplemental (OSS) payments, the change must be 

coordinated with the recipient’s DCF case manager. 

July 2001 2-14



Leave of Absence and Discharge, continued 

Move to a Non- 

ACS Provider or to 

Unlicensed Setting 

Changes in residence for a recipient who receives Optional State 

Supplementation (OSS) payments must be coordinated with DCF. If it 

appears that a nursing facility or other placement is necessary, the facility must 

coordinate with the DCF case manager. If the resident participates in the 

ALE Waiver, the local Department of Elder Affairs (DOEA) Comprehensive 

Assessment and Review for Long Term Care Services (CARES) unit must 

also be included in coordinating the plan to seek an appropriate placement. 

The discharging facility may not bill ACS for the day of discharge. 

Termination of Services 

Introduction 

In most cases, ACS recipients must be given a written 10-day advance notice 

of termination including their right to request a fair hearing. 

Reasons for 

Termination 

Termination of ACS for any of the following reasons triggers the requirement 

for a 10-day written notice: 

• Loss of Medicaid eligibility; 

• The recipient’s condition no longer meets functional criteria; 

• The recipient voluntarily moves out of the facility to a non-ACS setting; 

• The recipient elects to stop assistive care services; or 

• Transfer to a non-participating ALF, RTF, or AFCH. 

Right to a Fair 

Hearing 

An ACS consumer has the right to appeal any action taken by the facility, 

AHCA, DOEA, or DCF that adversely affects the recipient’s receipt of 

services. 



July 2001 2-15



July 2001 2-16



PART I 

CHAPTER 3 


PROCEDURE CODES AND FEES 

Overview 

Introduction 

This chapter provides and describes the procedure codes and approved fees 

for the Assistive Care Services (ACS) program. 

In this Chapter 


TOPIC 

PAGE 

Reimbursement Information 3-1 

Appendix A: Procedure Code Table and Fees A-1 

Appendix B: Appeal Rights and Fair Hearing Process B-1 

Appendix C: Optional Certification of Medical Necessity 

Form 

Appendix D: Optional ACS Service Plan From and 

Instructions 

Appendix E: Optional Resident Service Log and 

Instructions 

C-1 

D-1 

E-1 

Reimbursement Information 

Introduction 

Medicaid reimburses for assistive care services procedure code based on the 

Healthcare Common Procedure Coding System (HCPCS), Level III 

procedure codes and locally assigned codes that have been approved by 

CMS, formerly known as HCFA. Locally assigned codes are identified by a 

“W” prefix. 

July 2001 3-1



Reimbursement Information, continued 

Medicaid 

Reimbursement 

Claim Form 

Assistive care services are billed on the HCFA-1500 and the 081 Non- 

Institutional claim forms. ALFs that do not participate in the ALE Waiver 

program will use the HCFA-1500 claim form. ALE ALFs will bill for ACS on 

the 081 Non-Institutional claim form. 

Note: See the Medicaid Provider Reimbursement Handbook, HCFA-1500 

and Child Health Check-Up 221 and the Medicaid Provider 

Reimbursement Handbook, 081-Non-Institutional, for specific procedures 

for submitting claims for payment. 

Procedure Code 

Table 

There is one reimbursable service in the assistive care service program. The 

procedure code is found in Appendix A of this chapter. The service and its 

components have been explained in Chapter 2 of this handbook. The table 

gives: 

• The procedure code associated with the service; 

• The name of the service; and 

• The fee that Medicaid will reimburse for the service. 

Billing for Assistive 

Care Services (ACS) 

Assistive care service components are reimbursed at a single per diem rate. 

Assistive care services providers are encouraged to bill at the end of each 

calendar month. Claims for less than one calendar month will be paid as billed. 

However, if a claim encompasses more than one calendar month, the claim will 

be paid based only on the number of days billed for the first month. 

If the recipient is admitted to a hospital or a nursing facility from the ACS 

facility, the last date of service (DOS) for ACS must be the day before the 

recipient’s admission to the other facility. 

July 2001 3-2




Billable Days for 

ACS 

Reimbursement will be made only for days the resident is eligible for and is 

receiving services in the facility. 

ACS providers cannot bill for those days a resident is not eligible for Medicaid. 

In case of a resident who is not initially Medicaid-eligible, but who applies for 

and is determined eligible for Medicaid, the provider can bill for services from 

the effective date of Medicaid eligibility as shown on the Notice of Case 

Action. 

If the resident’s need and eligibility for ACS commence with admission to the 

facility, reimbursement will be made from the day of admission. 

Reimbursement will not be made for the day of discharge from the facility. 

Reimbursement will not be made when the recipient is absent for 24 hours or 

more. In such cases, reimbursement will be made for the day the resident 

returns, but not the day the resident leaves. 

Note: See Chapter 3 of the Medicaid Provider Reimbursement Handbook, 

HCFA-1500 and Child Health Check-Up 221 and the Medicaid Provider 

Reimbursement Handbook, 081-Non-Institutional, for more information 

regarding Medicaid recipient eligibility 

Personal 


ACS providers agree to accept Medicaid payment as payment in full for 

assistive care services. ACS providers cannot accept or solicit payments from 

recipients or others for assistive care services. Facilities may accept 

contributions from recipients and others for the cost of room, board, and for 

services other than ACS. 

July 2001 3-3



APPENDIX A 


PROCEDURE CODE TABLE AND FEES 

CODE DESCRIPTION OF SERVICE UNIT PER DIEM RATE 

W9659 ACS for Non-waiver recipients Daily $9.28 

*Note for ALE Waiver providers use only. Procedure Code W-9657 must be used to bill for ACS 

services provided to ALE waiver recipients. For more information, ALE waiver providers 

can consult Chapter 6 of this handbook. 

July 2001 A-1



PART I 

APPENDIX B 

APPEAL RIGHTS AND FAIR HEARING PROCESS 

Fair Hearing Process 


Hearing 

An ACS recipient or applicant has the right to appeal any action taken by the 

Agency for Health Care Administration (AHCA), Department of Children and 

Families (DCF) or service providers that adversely affects the recipient’s receipt 

of services. 

ACS recipients must be given at least 10 calendar days advance written notice 

of any suspension, reduction, or termination of services or program participation. 

The advance notice must inform the ACS recipient of the right to a fair hearing. 

Where to Apply for 

a Hearing 

Hearing requests must be sent to the DCF, Office of Hearing Appeals (OSIH), 

1317 Winewood Boulevard, Building 5, Room 203, Tallahassee, Florida 

32399-0700. The telephone number is (850) 488-1429. 

How to Request a 

Hearing 

The ACS applicant, recipient, or authorized representative must request a 

hearing within 90 days of the receipt of the written notification of the adverse 

decision. ACS providers must offer assistance to recipients or applicants with 

the fair hearing process. 

Continuation of 

Benefits 

If the ACS applicant, recipient, or authorized representative requests a fair 

hearing within 10 calendar days of the receipt of the notice of case action or 

denial of service, ACS services must be reinstated at the level prior to the 

adverse action. 

If an ACS applicant or recipient requests a fair hearing and services are 

reinstated to the prior level, the recipient might be requested to repay that 

portion of the benefits that the hearing decision determines to be invalid. The 

recipient must be given written notice of this responsibility. 

July 2001 B-1

Assistive Care Services and Assisted Living for the Frail Elderly Waiver Services 


Fair Hearing Process, continued 

Reinstated Benefits 

Reinstated or continued benefits must not be reduced or terminated prior to the 

final hearing decision unless an additional cause for adverse action occurs while 

the hearing decision is pending and the recipient fails to request a hearing after a 

subsequent notice of adverse action. 

The ACS provider must inform the recipient or authorized representative in 

writing if benefits are reduced or terminated prior to the hearing decision. 

Notification of Fair 

Hearing Decisions 

The hearing officer must send the applicant, recipient, or the authorized 

representative a copy of the final order. In addition to describing the final 

decision of the hearing, the final order explains: 

• The applicant, recipient, or authorized representative can request a judicial 

review of the decision; and 

• The applicant, recipient, or authorized representative must pay the cost of 

any judicial review. 

Time Limit on 

Hearing Decision 

Federal law requires the final hearing decision must be made and communicated 

to all involved parties within 90 calendar days of the hearing request. 

Necessary Actions 

to be Taken When 

Appeal is Granted 

Recipient benefit restoration or increases resulting from the final hearing decision 

must begin within 10 calendar days of the date the local office is notified. Benefit 

increases are effective based on the date specified by the hearings officer. 

July 2001 B-2



PART I 

APPENDIX C 


The following page contains the Certification Of Medical Necessity For Medicaid Assistive Care 

Services, an optional form. The form may be copied and used by providers to document medical 

necessity. 

July 2001 C-1

CERTIFICATION OF MEDICAL NECESSITY 

FOR MEDICAID ASSISTIVE CARE SERVICES 

Optional Form 

Patient Name ________________________________________ DOB _____________ 

This is to certify that this patient is in need of an integrated set of assistive care services on a 24-hour 

basis, including at least two of the following four service components (check as applicable): 

____ Assistance with activities of daily living, which is defined as individual assistance 

with ambulating, transferring, bathing, dressing, eating, grooming, and/or 

toileting. 

____ Assistance with instrumental activities of daily living, which is defined as 

individual assistance with shopping for personal items, making telephone calls, 

managing money, etc. 

____ Health support, which is defined as observing the resident’s whereabouts and wellbeing; 

reminding the resident of any important tasks; and recording and 

reporting any significant changes in appearance, behavior, or state of health to the health 

care provider, designated representative, or case manager. 

____ Assistance with self-administration of medication, which is defined as assistance 

with or supervision of self-administration of medication as permitted by law. 

HEALTH CARE PROVIDER (Not an employee of the ACS facility): 

Typed Name 

License Number 

Signature 

Date Signed 

____________________________________________ 

____________________________________________ 

____________________________________________ 

____________________________________________ 

RETURN TO: 

Facility Name & Address 

Contact Person & Phone # 

____________________________________________________ 

____________________________________________________ 

(AHCA Form 5000-3100B July 2001)



PART I 

APPENDIX D 


SERVICE PLAN FORM INSTRUCTIONS 

The following pages contain an optional service plan form for assistive care services. The form may be 

copied and used by providers to document the service plan. 

ACTIVITIES 

General Information 

The activities on this form match those listed on the DOEA Health Assessment Form and the service 

components on the Medical Necessity Certification. If the individual does not need any help with an 

activity, check "Independent." 

SERVICE 

The level of service to be provided (supervision, assistance, total help, etc.) should match the need 

shown on the Health Assessment7. 

• If the individual is independent in an activity, no other information need be provided for that 

activity. 

• Providing supervision generally means reminding the individual to perform the activity, cueing the 

individual as to how to do the activity, and monitoring that the individual completes the activity. 

• Providing assistance includes the tasks specified below under each activity on a daily basis. 

• Providing total help means that the provider performs the entire activity for the resident because 

the resident is unable to perform any part of the activity for himself/herself. 

PROVIDER 

Show who will be responsible for providing the service needed. If the provider is other than Facility 

Staff, specify who will be responsible, for example, daughter or home health agency. 

EXPECTED OUTCOME 

Specify how the resident is expected to function when the proper amount and type of care is provided; 

the purpose of the service. 

OTHER 

Specify any other information about the service to be provided. 

July 2001 D-1



AMBULATION 

Activities and Services 

Assistance includes: Providing physical support to enable the resident to move about within or outside 

the facility. Physical support includes supporting or holding the resident's hand, elbow, or arm; holding 

on to a support belt worn by the resident to assist in providing stability or direction while the resident 

ambulates; or pushing the resident's wheelchair. The term does not include assistance with transfer. 

Example of an expected outcome for Ambulation: Resident will be able to move about as needed. 

BATHING 

Assistance includes: Assembling towels, soaps, and other necessary supplies; helping the resident in 

and out of the bathtub or shower; turning the water on and off; adjusting water temperatures, washing 

and drying portions of the body which are difficult for the resident to reach; or being available while 

the resident is bathing. 

Example of an expected outcome for Bathing: Resident will be able to maintain body hygiene. 

DRESSING 

Assistance includes: Helping the resident to choose and to put on and remove clothing. 

Example of an expected outcome for Dressing: Resident will be appropriately dressed. 

TOILETING 

Assistance includes: Assisting the resident to the bathroom, helping to undress, positioning on the 

commode, and helping with related personal hygiene, including assistance with changing an adult brief. 

Assistance with toileting includes assistance with routine emptying of a catheter or colostomy bag. 

Example of an expected outcome for Toileting: Resident will maintain hygienic body functions 

EATING 

Assistance includes: Helping with cutting food, pouring beverages. 

Example of an expected outcome for Eating: Resident will be able to consume an adequate and 

appropriate diet. 

GROOMING 

Assistance includes: Physically helping the resident with shaving, with oral care, with care of the hair, 

and with nail care. 

Example of an expected outcome for Grooming: Resident's teeth, nails, hair, etc., will be adequately 

groomed. 

July 2001 D-2

TRANSFERRING 



Assistance includes: Providing verbal and physical cueing or physical assistance or both while the 

resident moves between bed and a standing position or between bed and chair or wheelchair. 

Example of an expected outcome for Transferring: Resident will be able to move from bed to chair 

and standing position or wheelchair as needed. 

MEDICATIONS 

If assistance is required with prescribed medications, the rule requirements for medication assistance 

applicable to the provider type must be followed. 

Non-daily medication supervision is not considered assistance. 

Example of an expected outcome for Medications: Resident will take medications as prescribed, and 

concerns will be communicated to health care provider. 

MAKING TELEPHONE CALLS 

Assistance includes: Dialing a number for a resident unable to do so. 

Example of an expected outcome for Making Telephone Calls: Resident will be able to make 

telephone calls as needed. 

MANAGING MONEY 

Assistance includes: Facility staff manages resident’s funds as representative payee or power of 

attorney. Such assistance must comply with Section 400.424, FS. 

Example of an expected outcome for managing money: Resident’s funds will be spent as desired by 

the resident. 

SHOPPING FOR PERSONAL ITEMS 

Assistance includes: Purchasing items the resident chooses. 

Example of expected outcome for shopping for personal items: Resident will be able to obtain desired 

items. 

USING AVAILABLE TRANSPORTATION 

Assistance includes: Making arrangements for transportation needed by resident and supervising or 

physically assisting resident into/out of the vehicle. 

Escort includes: Providing or arranging for someone to accompany the resident while off-site. 

Example of expected outcome for Using Available Transportation: Resident will safely access off-site 

services and activities. 

REMINDING RESIDENT OF IMPORTANT TASKS 

Daily tasks could include meals, getting up and going to bed, attending activities, etc. 

Example of expected outcome for Reminding Resident of Important Tasks: Resident will know to do 

specified tasks. 

July 2001 D-3



OBSERVING RESIDENT’S APPEARANCE AND WELL-BEING 

Daily observation includes observing and interacting with resident each day, noting deviations from the 

resident’s normal state of health and well-being, and contacting the health care provider, case 

manager, or others as appropriate. 

Example of expected outcome for Observing Resident’s Appearance and Well-being: Staff will be 

aware of resident’s normal base line and will respond appropriate when deviations occur. 

Completion of Service Plan 

The service plan must be signed by the provider representative. 

• For an ALF, the provider must be the facility administrator or a person designated in writing by the 

administrator. 

• For an AFCH, the provider who is the licensee or the designated relief person in the absence of 

the provider must sign the service plan. 

The service plan must be signed by the resident except: 

• If the resident has a legal guardian, the guardian must sign the form on the resident's behalf. 

• If the resident has a representative or designee established pursuant to Section 400.402, Florida 

Statutes, that person may sign the form on the resident's behalf. 

The service plan is considered complete as of the last date signed by either party. 

Time Frames 

For a new resident, the service plan must be completed no more than 15 days after admission (or the date 

of the health assessment if after admission). 

A new service plan must be completed annually, which means no more than 15 days after the annual 

health assessment. 

A new service plan must be completed no more than 15 days after a health assessment is performed due 

to a significant change in the condition of the resident. 


A sudden or major shift in behavior or mood, or a deterioration in health status such as unplanned weight 

change, stroke, heart condition, or stage 2, 3, or 4 pressure sore. Ordinary day-to-day fluctuations in 

functioning and behavior, a short-term illness such as a cold, or the gradual deterioration in the ability to 

carry out the activities of daily living that accompanies the aging process are not considered significant 

changes. 

--Rule 58A-5.0131, Florida Administrative Code 

July 2001 D-4

RESIDENT SERVICE PLAN FOR ASSISTIVE CARE SERVICES 

(Optional Form) 

FACILITY: 

DATE: 

RESIDENT NAME: MEDICAID #: 

Beginning Date of Service Plan ____________________ 

Ending Date of Service Plan_________________ 

ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLs) 

ACTIVITY SERVICE NEED PROVIDER 

AMBULATION 

o Independent 

o Provide Assistance 

o Assist with Ambulatory Device 

o Wheelchair o Walker o Cane 

o Facility Staff 

Other ________________________ 

Expected Outcome of Service: _____________________________________________________________________ 

Comments: _____________________________________________________________________________________ 

BATHING 

o Independent 

o Provide Supervision 


o Provide Total Help 

o Tub 

o Shower 

o Morning 

o Evening 


Other _______________________ 


Comments: _____________________________________________________________________________________ 

DRESSING 

Choose 

attire 

o 

o 

o 

o 

Put on 

shoes 

o 

o 

o 

o 

Dress/ 

Undress 

o 

o 

o 

o 

Independent 

Provide Supervision 

Provide Assistance 

ProvideTotal Help 




Comments: _____________________________________________________________________________________ 

TOILETING 

o Independent 

o Supervision/Prompting 


o Incontinent: 

o Bladder o Bowel 

o Adult Brief 

o Catheter Care 

o Ostomy 

Assistance 



Expected Outcome of Service: _______________________________________________________________________ 

Comments: _______________________________________________________________________________________ 

EATING 

Special diet: 

o Independent 




o Hand Guidance 

o Cutting Food 

o Opening Packages 



o Regular o Diabetic o No added salt o Low fat/Low cholesterol Other _________________ 

Expected Outcome: _______________________________________________________________________________ 

Comments: ______________________________________________________________________________________ 

AHCA FORM 2900 (July 2001) Page 1 of 3

GROOMING 

o Independent 




o Teeth 

o Hair 

o Nails 

Other____________ 




Comments: _____________________________________________________________________________________ 

TRANSFERRING 

o Independent 






Comments: _____________________________________________________________________________________ 

ASSISTANCE WITH SELF-ADMINISTERED MEDICATION 


MEDICATIONS 

o Independent 

o Provide Daily Supervision or Assistance 

o Provide Administration 

o Facility Non-Nursing Staff 

o Facility Nursing Staff 

Other ________________________ 


Comments: _____________________________________________________________________________________ 

ASSISTANCE WITH INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs) 


MAKING A 

TELEPHONE 

CALL 

o Independent 

o Supervision/ Prompting 

o Dial Number 


Other ___________________ 


Comments: ____________________________________________________________________________________ 

MANAGING 

MONEY 

o Independent 


o Representative Payee or Power of Attorney 




Comments: _____________________________________________________________________________________ 

SHOPPING FOR 

PERSONAL ITEMS 

o Independent 






Comments: _____________________________________________________________________________________ 


USING AVAILABLE 

TRANSPORTATION 

o Independent 


o Provide Assistance or Escort 




Comments: _____________________________________________________________________________________ 

HEALTH SUPPORT 


REMINDING 

RESIDENT OF 

IMPORTANT TASKS 

o Independent 

o Appointments 

o Daily Tasks 

o Other ____________________________ 




Comments: _____________________________________________________________________________________ 

OBSERVING RESIDENT’S 

APPEARANCE AND WELL-BEING 

o Weekly or Less 

o Daily 

o Other ____________________ 




Comments: _____________________________________________________________________________________ 

OTHER SERVICES 



Comments: _____________________________________________________________________________________ 


Comments: _____________________________________________________________________________________ 

CONSUMER COMMENTS: 

Facility Administrator or Designee DATE Resident or Representative DATE 




PART I 

APPENDIX E 


RESIDENT SERVICE LOG 

The following page contains an optional resident service log for assistive care services. The form may 

be copied and used by providers to document the resident service log. 

INSTRUCTIONS 

Set Up the Form 

• Fill in the name of the provider and the month and year. 

• Fill in the names and Medicaid numbers of current residents. 

• If there are less than 31 days in the month, cross out extra days. 

How to Code Your Census 

Each day, code who was or was not in the facility on the previous day. For example: On the second 

day of the month, enter "Y" for residents who were in the facility and "N" for residents who were not in 

the facility on the first day of the month. 

As new residents are admitted during the month, add them to the form and code as appropriate. 

Admission and Discharge 

You can bill Medicaid for the day the person is admitted to the facility, but you cannot bill Medicaid for 

the day the person is discharged from the facility. 

• Code the day the person was admitted as "Y." 

• Code the day the person was discharged as "N." 

Temporary Absences 

You cannot bill Medicaid for temporary absences of more than 24 hours. Such absences might be for 

hospitalization, home visits, etc. 

• Code the day the person left the facility as "N." 

• Code the day the person returned to the facility as "Y." 

Completing the Form 

At the end of the month, total the number of days (Y) each resident was in the facility and enter in the 

Days column at the right. 

Total the number of residents in the facility each day at the bottom. 

Add both sets of figures--you should have the same total each way. 

July 2001 E-1


(Optional Form for Medicaid Assistive Care Services) 

FACILITY NAME ____________________________________________ 

MONTH & YEAR _____________________________________ 

Resident Name Medicaid # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Days 

(AHCA Form 5000-3100A July 2001)

TOTALS 



(Optional Form for Medicaid Assistive Care Services) 

FACILITY NAME _____Stars ALF______________________________ 

MONTH & YEAR _____February 2000___________________ 

T 

1 

F 

2 

S 

3 

S 

4 

M 

5 

T 

6 

W 

7 

T 

8 

F 

9 

S 

10 

S 

11 

M 

12 

T 

13 

W 

14 

T 

15 

F 

16 

S 

17 

S 

18 

M 

19 

T 

20 

W 

21 

T 

22 

F 

23 

S 

24 

S 

25 

M 

26 

T 

27 

W 

28 29 30 31 Days 

Resident Name Medicaid # 

Gibson, Mel 000 Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y x x x 24 

Midler, Bette 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 28 

Cruise, Tom 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 28 

Roberts, Julia 000 Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y x x x 26 

Newman, Paul 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N x x x 20 

Grier, Pam 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 28 

Pitt, Brad 000 Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 25 

Streep, Meryl 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 28 

Smith, Will 000 Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 28 

Ryan, Meg 000 N N N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y x x x 23 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

x x x 

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TOTALS 9 9 8 8 9 9 8 8 9 10 9 10 10 10 10 10 10 10 9 10 9 9 9 8 8 9 9 9 0 0 0 253 


Overview 



PART II 

CHAPTER 4 


PURPOSE, BACKGROUND, AND PROGRAM SPECIFIC INFORMATION 

Introduction 

This chapter describes Florida Medicaid’s Assisted Living for the Elderly 

(ALE) waiver services program, specifies the authority regulating ALE 

waiver services, the purpose of the program, and provider qualifications and 

responsibilities. 


Medicaid waiver programs, also called home and community-based services 

(HCBS), are authorized under Section 1915(c) of the Social Security Act 

and governed by Title 42, Code of Federal Regulations (C.F.R.), Part 

441.300. 

The Florida Medicaid ALE waiver is authorized by Chapter 409, Florida 

Statutes (F.S.) and the Florida Administrative Code (F.A.C.), Chapter 59G- 

8.200. 



TOPIC 

PAGE 

Description and Purpose 4-1 

Provider Qualifications and Responsibilities 4-2 

Description and Purpose 

ALE Waiver 

Description 

The ALE waiver is a Medicaid program that provides extra support and 

supervision through provision of home and community based services to 

eligible recipients living in assisted living facilities (ALFs) licensed for 

extended congregate care (ECC) or limited nursing services (LNS). 

July 2001 4-1



Description and Purpose, continued 

ALE Waiver 

Description, 

continued 

ALE waiver recipients must demonstrate functional deterioration that would 

result in placement in a nursing facility were it not for the provision of ALE 

waiver services. 

Purpose 

The purpose of the ALE waiver program is to promote, maintain, and 

restore the health of eligible recipients, and to minimize the effects of illness 

and disability in order to delay or prevent institutionalization. 

The program provides assisted living services, incontinent supplies, and case 

management services to eligible recipients living in ALFs, to enable them to 

live in the home-like setting of an ALF as long as possible. 

Medicaid 

Reimbursement 

This portion of the handbook is intended for use by ALFs and case 

management agencies that provide ALE waiver services to eligible recipients 

in assisted living facilities. It must be used in conjunction with the Medicaid 

Provider Reimbursement Handbook, Non-Institutional 081, which 

contains information about the Medicaid program in general, as well as 

specific procedures for submitting claims for payment. 

Provider Qualifications and Responsibilities 

Introduction 

The ALE waiver program is jointly administered by the Agency for Health 

Care Administration (AHCA), the Department of Elder Affairs (DOEA) and 

the Department of Children and Families (DCF). 

• AHCA is responsible for assuring compliance with federal program 

requirements, developing Medicaid policy, and for reimbursing Medicaid 

providers. 

July 2001 4-2




Introduction, 

continued 

• DOEA is responsible for the operational administration of the program 

and determining level of care (LOC). 

• DCF is responsible for determining the recipient’s financial eligibility. 

Area Agency on 

Aging and Medicaid 

Waiver Specialist 

An Area Agency on Aging (AAA) is located in each DOEA-designated 

planning and services area (PSA). 

The AAA employs a Medicaid waiver specialist who is responsible for: 

• Receiving waiver enrollment packets from ALFs and case management 

agencies; 

• Verifying with AHCA that ALF providers meet licensure requirements 

and ensuring case management agencies meet waiver standards; 

• Facilitating enrollment of eligible providers with the Medicaid fiscal agent; 

• Training providers and furnishing technical assistance; 

• Monitoring recipient case records through on-site reviews conducted in 

provider facilities; 

• Preparing written monitoring reports for the provider, DOEA, and 

AHCA; 

• Managing the PSA-wide general revenue budget spending authority; and 

• Coordinating with Area Medicaid offices, DCF, and the Medicaid fiscal 

agent, as needed. 

Note: To obtain a list of AAA addresses and telephone numbers, contact 

DOEA Medicaid Waiver Programs by telephone at: (850) 414- 

2000; 994-2000 (Suncom); on the Elder Affairs Web Site, 

http://elderaffairs.state.fl.us; or by mail at 4040 Esplanade Way, 

Suite -315, Tallahassee, Florida 32399-7000. 

July 2001 4-3




ALE Waiver Facility 

Provider 


Medicaid ALE waiver providers must: 

• Be enrolled with the Medicaid fiscal agent as an ALE waiver provider; 

• Not be currently suspended from Medicare or Medicaid in any state; 

• Be licensed by the Division of Health Quality Assurance (HQA) under 

Chapter 400, Part III, F.S., for ECC or LNS; and 

• Specify a staff member to serve as the facility supervisor authorized to 

sign service plans, if the administrator does not perform this function. 

Facility Provider 


ALFs are required by licensure to provide sufficient staff and a variety of 

services to all individuals residing in assisted living facilities. 

The facility staffing for waiver recipients must be based on the amount and 

type of services provided to recipients as authorized in plans of care and in 

accordance with recipient service needs documented in the consumer 

assessment. 

ALFs must provide 24-hour on-site staff to meet scheduled or unpredicted 

needs and to provide supervision for safety and security. 

ALE waiver providers must also: 

• Provide each recipient with a private room or apartment or a semiprivate 

room or apartment shared with a roommate of the recipient’s 

choice and consent; 

• Develop a service plan for each ALE waiver recipient; 

• Specify a staff member to serve as the facility supervisor authorized 

to sign service plans, if the administrator does not perform this 

function; 

• Comply with all provisions of the Medicaid Provider Agreement; 

and 

• Cooperate with Medicaid monitoring staff or its designated 

representatives. 

July 2001 4-4




Vendor 


If an ALF purchases services from a vendor, the vendor and staff must meet 

all mandatory educational, licensing, and certification requirements for the 

specific area of service furnished. 

Referral Agreement 

To be reimbursed by Medicaid for ALE waiver services, and prior to the 

provision of services, each ALF and case management agency must have on 

file with the AAA, a completed, signed and dated Assisted Living Medicaid 

Waiver Referral Agreement. Referral agreements are available from the 

Medicaid Waiver Specialists in each DOEA Planning and Services Area 

(PSA). 

Case Management 

Case managers begin the assessment process for applicants for entry into the 

ALE waiver program and provide ongoing case management oversight of 

recipient’s care in ALFs. 

There can only be one case manager for an ALE recipient. If a recipient has 

a Department of Children and Families placement worker, the ALE case 

manager must be designated as the sole case manager when the recipient 

becomes an ALE waiver recipient. However, the DCF placement worker 

will continue to process Optional State Supplementation (OSS), reviews, 

placement, and other associated OSS responsibilities. 

July 2001 4-5




Agency 


Case management ALE waiver providers must be a designated Community 

Care for the Elderly lead agency in accordance with Chapter 430, F.S. or 

meet the following standards: 

• Employ case management staff with skills, knowledge, education, and 

experience to link consumers to community-based services and 

resources appropriate to meet their needs; 

• Have personnel policies which meet or exceed federal, state, DOEA, 

AHCA, and AAA and local requirements for licensure, certification, or 

other special education and training qualifications for specific personnel 

functions; 

• Have case managers trained and certified on relevant DOEA forms. A 

minimum score of 80% on the assessment training is required. 

July 2001 4-6





Agency 

Qualifications, 

continued 

• Have case managers who have successfully completed Assisted Living 

Facility core training within six months of beginning to serve recipients 

under this waiver; 

• Develop and provide in-service training of at least 4 hours per year for 

case managers; training content and length must be documented in staff 

records. Training must include due process rights of consumers; 

• Conduct intake, screening, prioritization, and assessment of individuals in 

accordance with the DOEA Intake and Assessment Training Handbook, 

(Form 701D); 

• Maintain 24-hour, 7-day-a-week on-call staff capability for emergency 

services referrals including those from DCF and Adult Protective 

Services (APS) workers. Assess and initiate services within 72 hours, 

or in accordance with local protocols, if determined by the APS to be in 

need of immediate services to prevent harm; 

• Report suspected instances of abuse, neglect, or exploitation of disabled 

or elderly persons to the Florida Abuse Hotline; 

• Have procedures in place for making referrals, accepting referrals, and 

serving referrals from other agencies; 

• Initiate and maintain coordination among agencies providing service and 

referrals to consumer within the community; 

• Establish and maintain communications and coordination with other 

agencies serving clients in common; 

• Complete and maintain case records in accordance with the DOEA care 

plan handbook; 

• Have the staff and capability to collect, analyze, and transmit consumer 

demographic and service data electronically; 

• Have administrative and supervisory staff available on-site to provide 

oversight and direction to case management staff, ensure compliance 

with accounting and financial requirements, and develop and implement 

quality assurance measures including cost effectiveness; 

• Have adequate procedures in place to avoid any potential for conflict of 

interest between the role of case management and service provision; 

• Have a process to monitor quality provision of service providers; 

July 2001 4-7





Agency 

Qualifications, 

continued 

• Maintain caseloads no greater than 60 individuals; 

• Observe confidentiality requirements; 

• Have procedures in place which assure applicants and consumers are 

educated of their right to file a grievance and afforded all due process 

rights; 

• Prepare and update as needed a disaster preparedness plan which 

includes training and coordination with the local emergency management 

office; and 

• Maintain financial capability including having a minimum of a 60 day 

operating reserve in the form of cash or current credits. 

Case Manager 


An ALE waiver case manager must have a bachelor’s degree in social work, 

sociology, psychology, or a related social services field and have one year of 

related professional experience. If the bachelor’s degree is not in a social 

services field, two years of related professional experience is required. 

Professional human services experience may substitute on a year for year 

basis for the educational requirement. 

An ALE case manager must be an employee of an enrolled case 

management agency and successfully complete assisted living core training 

within the first six months of employment. 

July 2001 4-8




Case Manager 


The case manager is responsible to: 

• Assist ALE applicants with making application for Medicaid waiver 

services; 

• Advise the ALE applicant and recipient of their fair hearing rights and the 

grievance process; 

• Develop and implement an assessment-based plan of care for each 

recipient; 

• Review plans of care every three months to assure the continued need 

for waiver services; 

• Visit each recipient at least once every 30 days and document the 

recipient’s status, satisfaction with services and additional service needs 

in the recipient’s case record; 

• Maintain up-to-date recipient case records; 

• Coordinate other services provided to the consumer, including hospice 

and Medicare with the ALE service provider for waiver recipients 

electing to receive those services; 

• Contact the service provider when there is indication that needed 

services are not being rendered in order to have those services reinstated 

immediately; 

• Contact the Agency for Health Care Administration, Health Quality 

Assurance (MC/HQA) simultaneously with the Medicaid waiver 

specialist within 24 hours of a site visit if a recipient is not receiving 

needed services; and 

• Notify the Florida Abuse Hotline immediately in cases where lack of 

service provision endangers the recipient’s health, safety, or welfare. 

Medicaid Fraud and 

Abuse 

See Chapter 5 of the Medicaid Provider Reimbursement Handbook, 

Non-Institutional 081, for information regarding Medicaid policy on 

provider abuse and fraud and Medicaid’s recoupment policies. 

July 2001 4-9

Overview 



PART II 

CHAPTER 5 


COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS 

Introduction 

This chapter describes the services covered under the Florida Medicaid 

Assisted Living for the Elderly (ALE) waiver. It also describes the 

requirements for service provision, service limitations, and exclusions. 



TOPIC 

PAGE 

Requirements To Receive Services 5-1 

Case Management Requirements 5-4 

Case Management Documentation 5-5 

Plan of Care 5-6 

Plan of Care Review and Reassessment 5-9 

ALE Waiver and Assistive Care Covered Services 5-9 

Placement and Discharge 5-17 

Termination of Services 5-18 

Requirements to Receive Services 

Introduction 

Medicaid can reimburse for services provided in assisted living facilities 

(ALFs) to eligible Medicaid recipients who are enrolled in the ALE waiver 

program. 

July 2001 5-1




Medicaid 

Application 


Individuals who have not applied for and been determined eligible for 

Medicaid at the time they need ALE services must complete or have a 

designated representative complete and submit a Request For Assistance 

(RFA) to the local Department of Children and Families (DCF), Office of 

Economic Self-Sufficiency. 

Prior to determining eligibility, DCF will require verification that the individual 

is a resident of an enrolled ALF, is receiving case management, has a level of 

care, and has been determined to need ALE services in order to remain in the 

ALF or in order to move into an ALF. 

Who Can Receive 


To receive ALE waiver services, recipients in this waiver must be 60 years of 

age or older and meet the following requirements: 

• Medicaid eligible; 

• Determined disabled according to Social Security standards if under 65 

years of age; 

• Deemed appropriate for ALF placement by the facility administrator; 

• Moving out of a nursing facility or other institutional program, be an ALF 

resident needing additional services in order to remain in the ALF, or be 

living at home and determined at risk of nursing facility placement and 

desiring to move into an ALF; 

• Have a case manager employed by a waiver enrolled case management 

agency; and 

• Meet one or more functional criteria. 

Functional Criteria 

Functional criteria include limitations in activities of daily living (ADLs). 

ADLs are defined as bathing, dressing, grooming, ambulating, eating, toileting, 

and transferring. To qualify for ALE waiver assistance, the recipient must 

need an average of more than one hour of direct services per day and meet at 

least one of the following criteria: 

• Require assistance with four or more ADLs or three ADLs plus 

supervision or administration of medication; 

• Require total help with one or more ADLs; 

July 2001 5-2




Functional Criteria, 

continued 

• Have a diagnosis of Alzheimer’s disease or another type of dementia and 

require assistance with two or more ADLs; 

• Have a diagnosed degenerative or chronic medical condition requiring 

nursing services that cannot be provided in a standard ALF but are 

available in an ALF licensed for limited nursing or extended congregate 

care; or 

• Be a Medicaid-eligible recipient who meets ALF criteria, awaiting 

discharge from a nursing facility placement and who cannot return to a 

private residence because of a need for supervision, personal care, 

periodic nursing services, or a combination of the three. 

Level Of Care 

Level of care (LOC) determinations are made by the Department of Elder 

Affairs (DOEA) Comprehensive Assessment and Review for Long Term 

Care Services (CARES) unit. The level of care verifies that the recipient is at 

risk of institutionalization and gives the level of care the recipient would 

require upon institutional placement. 

An ALE waiver recipient must meet an Institutional Care Program (ICP) 

LOC requirement that is verified on a DOEA-CARES Form 603, 

Notification of Level of Care, which is completed by CARES. 

The LOC must be reviewed annually for all recipients and documented in the 

recipient’s case record. Case managers are required to track LOC 

reassessments to ensure that timely evaluations are conducted and should 

notify CARES whenever an overdue LOC reassessment is detected. 

Any applicant or consumer who is determined not to meet a level of care will 

be notified through the DCF Office of Economic Self-Sufficiency and notified 

of their right to request a fair hearing. 

Note: See Part II, Chapter 6, Appendix G of this handbook for fair hearing 


July 2001 5-3



Case Management Requirements 

Description 

Every ALE waiver recipient must have a case manager who is employed by 

a waiver enrolled case management agency. 

Case management includes identifying, organizing, coordinating, and 

monitoring services needed by a recipient. The case manager assists waiver 

recipients in gaining access to waiver services as well as other services, 

regardless of the funding source. 

Note: See Chapter 4, Case Manager Responsibilities for more information 

regarding the responsibilities of case managers. 

Components 

Case management must include the following documented activities: 

• Comprehensive needs assessment and identification of appropriate 

service needs; 

• Development of plans of care and authorization of services and service 

components; 

• Referral to available resources; 

• Coordination of hospice and waiver services when the ALE consumer 

elects hospice care; 

• Coordination of Medicare services with ALE waiver services; 

• Monitoring of services rendered; 

• Reassessment of recipient needs; and 

• Review of fair hearing rights. 

July 2001 5-4



Case Management Documentation 

Case Records 

A case record must be kept by the case manager for every recipient 

receiving ALE waiver services. The purpose of keeping this record is to 

assure that information regarding the recipient’s condition and service 

provision is contained and available for review at a single location. It is the 

basis of the recipient’s plan of care and the basis for quality assurance 

monitoring. 

The case manager is responsible for developing and maintaining the case 

record. The case manager must record all case management activities in the 

case narrative including: 

• Copies of all eligibility documents; 

• Assessments; 

• Plans of care, including accurate cost projections; 

• Case narratives; and 

• Affirmation of receipt of fair hearing rights. 

Case records are maintained by the case management agency at a central 

location. 


Handbook, Non-Institutional 081, for additional information about 

documentation requirements. 

Case Narrative 

Requirements 

All case management activities must be recorded in the case narrative. 

• The narrative must be clear and comprehensive, reflecting what the case 

manager has done to meet the needs identified in the plan of care. 

• There should be documentation of any information that the case manager 

has learned about the activities of others on behalf of the recipient. 

• The case narrative should also contain a record of the case manager’s 

observations of the recipient’s status and must be sufficient to justify 

payment. 

July 2001 5-5



Case Management Documentation, continued 

Permanent Record 

Documentation 

All case record documentation (including the case narrative), must be in ink 

and must be legible. No erasures or white out are permitted. Case narrative 

entries must be signed and dated by the case manager. In case of an error, 

the case manager lines through the error and initials and dates it, then makes 

the correct entry. 

Computer records 

Case narratives may be written on a computer. A printout of the narrative 

must be kept in the recipient’s case record. Each computer entry must be 

signed and dated by the case manager. 

Plan Of Care 

Description 

A plan of care is a written document that describes the service needs of a 

recipient, and specifically identifies the services and service components to 

be provided, the provider of services and service components, their 

frequency, duration, and estimated cost. 

The plan of care is based on a review of assessments by the facility 

administration and nursing staff, the DOEA Comprehensive Client 

Assessment and the CARES HRS-Med Form 3008, Health Assessment. 

The information gathered through these assessments is used by the case 

manager to establish the recipient’s plan of care and identifies both waiver 

and non-waiver services required to maintain the recipient in the ALF and 

reduce functional limitations in order to avoid nursing facility placement. 

In order for the ALE provider to bill for ACS, the plan of care must show a 

need for ALE waiver services, including an average of more than one hour of 

direct services per day. Services must be coordinated and monitored by the 

ALE case manager. 

July 2001 5-6



Plan Of Care, continued 

Purpose 

The purpose of the plan of care is to: 

• Enable the case manager and the recipient to summarize the findings of 

the Comprehensive Client Assessment (Form 701B); 

• Identify realistic goals for the recipient; 

• Identify problems that present barriers to attaining the goals; and then, 

• Develop outcomes and patterns of service delivery that will help resolve 

identified problems so that stated goals can be achieved. 

Comprehensive 

Client Assessment 

The case manager must conduct a comprehensive client assessment, DOEA 

Form 701B, by evaluating the recipient's health status, functional status, 

support system, and living environment. The case manager must make a 

face-to-face visit with the recipient to complete the assessment and may 

speak with the recipient’s formal and informal caregivers. The recipient must 

give permission for the case manager to contact the caregivers. 

The comprehensive client assessment must be placed in the recipient’s case 

record as a separately identifiable document. All contacts and visits made in 

completing the assessment must be noted in the case narrative. 

Plan of Care 

Contents 

The plan of care must be in writing, based on information obtained during the 

comprehensive assessment process and include: 

• Specific services and service components to be provided, with a 

beginning date for each; 

• Who will provide each service and component; 

• The amount, frequency, and duration of services and components; 

• Documentation of the dates that services and components are revised or 

terminated; 

• Projected service costs; and 

• The plan of care review date. 

July 2001 5-7



Plan Of Care, continued 

Plan of Care 

Contents, continued 

All waiver services or service components must be specified in the 

recipient’s plan of care. Services or service components not specified in the 

plan of care are not considered approved or authorized. Reimbursement for 

services furnished, but not specified in the plan of care for that specific time 

period, are subject to recoupment. 



Assistive Care Services are described in Part I of this handbook. These 

services are not covered services under the ALE waiver, but must be 

included in the waiver plan of care. The ACS components are health 

support, assistance with activities of daily living, assistance with instrumental 

activities of daily living, and medication assistance. ACS service provision is 

expected to take an average of about one hour per day. Recipients eligible 

for both ACS and ALE waiver assistance must have a service plan in which 

services that are considered ACS are shown and identified separately from 

those provided under the waiver. The same information should be shown for 

each ACS component as for each waiver service. 

Approval and 

Authorization 

The recipient, the recipient’s family or guardian, as appropriate, case 

manager and the facility administrator must meet to discuss and agree on the 

plan of care. 

The plan of care must be signed and dated by the recipient or, the recipient’s 

guardian or designated representative when the recipient is not competent to 

give his or her consent. 

When signing the plan of care, the recipient and the recipient’s family or 

guardian are informed that signing the plan of care indicates the recipient 

accepts ALE waiver services in lieu of nursing facility placement. The 

recipient and the recipient’s family or guardian are also notified in writing of 

the right to a fair hearing if services are denied, suspended, reduced, or 

terminated. The notice of rights must be sent by certified mail or hand 

delivered with a signed acknowledgement of receipt. 

The plan of care is considered authorized when it is signed and dated by the 

case manager. 

July 2001 5-8



Plan of Care Review and Reassessment 

Review 

The plan of care must be reviewed and updated to reflect the current needs 

of the recipient. For the purposes of case review, case managers must 

conduct a face-to-face visit at least quarterly, or more frequently depending 

on changes in the recipient’s condition. The case manager must monitor the 

plan of care for continuity of services and ensure that changes in the 

recipient’s status warrant service increases, service reductions, or other 

changes in the plan of care. This review is not a complete reassessment. 

The case manager must initial and date the plan of care at each review to 

certify that authorized services are appropriate and continue to be needed. 

Case reviews must be documented in the case narrative. 

Reassessment 

ALE waiver recipients must receive a quarterly review and updates. A 

complete reassessment must be performed annually. Complete 

reassessments are conducted by using the comprehensive client assessment 

instrument. If changes in the recipient’s condition warrant complete 

reassessment, one should be done more frequently than once a year. 

Reassessment results will be used to develop a new plan of care. 

Reassessments must be maintained in the recipient’s case record and all 

contacts and visits made in completing a reassessment must be noted in the 

case narrative. 

ALE Waiver and Assistive Care Covered Services 

Introduction 

ALE waiver services are based on individual recipient needs and must be 

documented in the plan of care. Recipients enrolled in the ALE waiver must 

receive: 

• Case management, and 

• Assisted living. 

The receipt of incontinence supplies is based on need. 

July 2001 5-9



ALE Waiver and Assistive Care Covered Services, continued 



Assistive Care Services is a Medicaid state plan service the ALE waiver 

providers may provide to their waiver recipients. This is not an ALE waiver 

service. 

Case 

Management 

W9655 

Case management is a service that provides the ALE waiver recipient with a 

case manager who will identify, organize, coordinate, and monitor the 

services needed by the recipient. The case manager also assists the recipient 

to access needed services. 

Assisted Living 

W9654 

Assisted living is a service that is comprised of an array of components 

provided by or through the ALF in which the recipient resides. These 

components will be provided only when the recipient is not capable of 

performing them and where no relative, caretaker, landlord, community 

volunteer or agency, or third party payor is capable or responsible for their 

provision. 

Each recipient must have a resident contract with the ALF that specifies 

services to be provided by the facility. Prior to including a service component 

into a recipient’s plan of care, the case manager must examine the recipient’s 

resident contract to determine if any needed service component is already 

covered by the facility’s basic charges and would be considered duplicative. 

Duplicative service components must not be included or authorized in the plan 

of care. 

The following components may be included in the assisted living service: 

• Attendant call system; 

• Attendant care; 

• Behavior management; 

• Chore services; 

• Companion services; 

• Homemaker services; 

• Intermittent nursing; 

• Medication administration; 

July 2001 5-10





W9654, continued 

• Occupational therapy; 

• Personal care; 

• Physical therapy; 

• Specialized medical equipment and supplies; 

• Speech therapy; and 

• Therapeutic social and recreational services. 

The criteria for provision of each component are explained below. 

Attendant Call 

System Component 

The attendant call system is an emergency response system for recipients 

who are at high risk of falling, becoming disoriented or experiencing some 

disorder that puts them in physical, mental, or emotional jeopardy requiring 

immediate assistance. The recipient either wears an electronic device (e.g., a 

medallion or a bracelet) or is in proximity to a button that enables him or her 

to summon emergency help from an ALF attendant. This component also 

includes alerting the attendant if the recipient wanders from the facility. 

Attendant Care 

Component 

Attendant care is hands-on care, of both a medical and non-medical 

supportive nature, specific to the needs of a medically stable, physically 

disabled recipient. Supportive services are those that substitute for the 

absence, loss, diminution, or impairment of a physical or cognitive function. 

Light housekeeping activities that are incidental to the performance of care 

may also be furnished as part of this component. 

Behavior 

Modification 

Component 

Behavior modification consists of specialized approaches to manage the 

behavior of recipients with dementia. These approaches are remedial 

measures aimed at preventing or ameliorating disruptive behaviors. They 

may include supervision of recipients with behavior problems due to 

dementia and educational activities for training caregivers to respond to 

recipients’ behavior. 

July 2001 5-11




Chore Services 

Component 

The chore component consists of services needed to maintain the home-like 

setting as a clean, sanitary, and safe environment. This component includes 

heavy household chores such as washing floors, windows and walls, tacking 

down loose rugs and tiles, and moving heavy items of furniture in order to 

provide safe access and egress. 

Companion Service 

Component 

The companion service component is provided to functionally impaired 

recipients and consists of non-medical care, supervision, and socialization. 

Companions may assist the recipient with activities such as meal preparation, 

laundry, and shopping, but do not perform these activities as discrete 

services. The provision of companion service does not entail hands-on 

medical care. Companions may perform light housekeeping tasks incidental 

to the care and supervision of the recipient. 

This component is provided in accordance with a therapeutic goal in the plan 

of care and is not intended to be diversional. 

Homemaker 

Component 

The homemaker component consists of general household activities (meal 

preparation and routine household care) provided by a trained homemaker. 

Intermittent Nursing 

Component 

Intermittent nursing consists of services provided by a licensed nurse on an 

as-needed basis to ensure therapeutic regimens such as changing dressings, 

administering medications, assessing the recipient’s state of health, and other 

activities within the scope of the nursing practice. 

Medicaid does not reimburse for continuous nursing services provided to 

ALE waiver recipients. 

July 2001 5-12




Medication 

Administration 

Component 

Medication administration, supervision and assistance may be provided to 

ALE waiver recipients as long as qualified staff is available to render the 

service component. 

Medication supervision and administration can only be provided by licensed 

nurses. Assistance with self-administered medications can be provided 

either by a licensed nurse or, with a documented request and informed 

consent, an unlicensed staff member. The unlicensed staff member must be 

trained to assist residents with self-administered medications, in accordance 

with Chapter 58A-5.0191(5), F.A.C., and must demonstrate the ability to 

accurately read and interpret a prescription label. Pursuant to 400.4256, 

F.S., assistance with self-administration of medications includes taking the 

medication from where it is stored and delivering to the resident; removing a 

prescribed amount of medication from the container and placing it in the 

resident’s hand or another container; helping the resident by lifting the 

container to his or her mouth; applying topical medications; and keeping a 

record of when a resident receives assistance with self-administration of his 

or her medications. 

Occupational 

Therapy 

Component 

Occupational therapy assists with the functional needs of recipients related to 

the performance of self-help skills, adaptive behavior and sensory, motor 

and postural development. Occupational therapy will be provided by 

licensed occupational therapists, occupational therapy assistants, or 

occupational therapy aides under the supervision and direction of a licensed 

occupational therapist. 

Personal Care 

Component 

The personal care component provides assistance with eating, bathing, 

dressing, personal hygiene, and other activities of daily living. This 

component may provide assistance with the preparation of meals and other 

housekeeping activities essential to the health and welfare of the recipient. 

July 2001 5-13




Physical Therapy 

Component 

The physical therapy component is directed toward the development, 

improvement, or restoration of neuromuscular or sensory motor function, 

relief of pain, or control of postural deviation to attain maximum 

performance. Physical therapy must be provided by licensed physical 

therapists, physical therapy assistants, or physical therapy aides under the 

supervision and direction of a licensed physical therapist. 

Specialized Medical 

Equipment and 

Supplies 

Component 

The specialized medical equipment and supplies component includes devices, 

controls, or appliances that are of direct medical or remedial benefit to the 

recipient. Such items must be specified in the plan of care and enable a 

recipient to increase his or her ability to perform activities of daily living, or to 

perceive, control, or communicate with the environment in which he or she 

lives. 

This component must include consultation with the recipient’s physician and 

denials from all other payment sources. 

Speech Therapy 

Component 

Speech therapy is provided when medical diagnosis indicates a need for 

treatment of speech and language disorders that result in a communication 

disability. This component is limited to the evaluation and treatment of 

speech disorders, such as aphasia, which result from stroke and cerebral 

trauma, dementia, or other degenerative neurologic diseases affecting oral 

motor functions. Speech therapy services must be provided by licensed 

speech-language pathologists or a certified speech-language pathology 

assistant under the supervision of a licensed speech-language pathologist. 

Therapeutic Social 

and Recreational 


Component 

The therapeutic social and recreational services component allows the ALF 

to provide activities to improve the mobility, motor skills, or alertness of ALE 

waiver recipients. These activities may also serve to divert the attention and 

enhance the quality of life of waiver recipients with dementia. 

July 2001 5-14





Service 

Components (This is 

a Medicaid state 

Plan service) 

The following components can be provided under the assistive care service 

plan: 





Each of the service components is described below. 

Health Support 

Component 

Health support is defined as requiring the provider to: 

• Observe the recipient’s whereabouts and well-being on a daily basis; 

• Remind the recipient of any important tasks on a daily basis; and 

• Record and report any significant changes in the recipient’s appearance, 

behavior, or state of health to the recipient’s health care provider, 

designated representative, or case manager. 


Activities of Daily 

Living (ADLs) 

Component 

Assistance with activities of daily living (ADLs) is defined as providing 

assistance with one or more of the following activities: individual assistance 

with ambulating, transferring, bathing, dressing, eating, grooming, and 

toileting. At least one service must be required daily. 


Instrumental Acts of 

Daily Living 

(IADLs) 

Component 

Assistance with instrumental activities of daily living (IADLs) is defined as 

providing intensive assistance with one or more of the following activities: 

individual assistance with shopping for personal items, making telephone 

calls, and managing money. 


Self-Administration 

of Medication 

Component 

Assistance with self-administration of medication is defined assistance with or 

supervision of self-administration of medication at least daily in accordance 

with licensure requirements applicable to the facility type. 

July 2001 5-15




Incontinence 

Supplies 

W9656 

Incontinence supplies are items essential to enabling health care personnel to 

carry out diagnostic and therapeutic care including ostomy or colostomy 

supplies, irrigation solutions, bedpans, adult diapers, bed pads and supplies 

necessary to maintain healthy skin. Such items must be specified in an 

approved plan of care. 



W9657 (This is a 

Medicaid state 

plan service.) 

Assistive care services are an array of services provided on a daily basis by 

or through ALE participating ALFs. 

The following components may be included in the assistive care service plan: 





The criteria for provision of each component are explained in a preceding 

section. 


Documentation 

The following specific elements must be documented for all ALE waiver 

services or service components rendered to waiver recipients: 

• Name of provider, provider agency, and specific individual rendering 

each service; 

• Type of service or service component provided; 

• Amount of service provided; 

• Date of service; and 

• Place of service. 

Case management documentation must clearly describe the activities 

associated with maintaining the recipient in the ALE setting. The 

documentation should show that services are consistent with the plan of care 

and are being delivered according to the plan. 

July 2001 5-16




Permanent Record 

Documentation 

All documentation must be in ink and must be legible. When computer 

records are used, a copy of the computer records are required to be printed, 

signed, dated, and maintained in the client file. No erasures or white out are 

permitted. All entries must be signed and dated. In case of an error, the 

provider must line through the error, initial and date it, then make the correct 

entry. 

Placement and Discharge 

Introduction 

Residency in an ALE enrolled ALF is a requirement of eligibility for receipt of 

ALE services. If a recipient has met all the criteria for receipt of ALE services 

except placement into an ALE enrolled ALF or is in one ALF and will be 

moving to another, according to the circumstances, denial of waiver services 

or termination from the ALE waiver may be necessary. Any time this occurs, 

the affected recipient will be advised of his or her appeal rights. 

Note: See Part II, Chapter 6, Appendix G of this handbook for fair hearing 


Nursing Facility 

Placement 

If a recipient who is receiving ALE services becomes too debilitated to 

remain in the ALF, the ALF in coordination with the case manager will 

contact CARES for an assessment and recommendation for appropriate 

nursing facility placement. 

Any time a nursing facility placement is necessary for an ALE waiver recipient 

who receives Optional State Supplementation (OSS) payments, the 

placement must be coordinated with DCF. 

July 2001 5-17



Placement and Discharge, continued 

Move To Another 

ALF 

If a recipient requests to move or is moved: 

• From one ALE-enrolled facility to another ALE-enrolled facility, the case 

manager will assist in coordinating the placement and the recipient will 

remain eligible to receive ALE services in the new ALF; or 

• From one ALE-enrolled ALF to an ALF that is not an ALE-enrolled 

waiver provider, the case manager will terminate the recipient from the 

ALE waiver and services will be discontinued. 

Any time a change in facilities is necessary for a recipient who receives 

Optional State Supplementation (OSS) payments, the change must be 

coordinated with DCF. 

ALF Discharge 

Requirements 

If an ALF administrator initiates discharge of an ALE recipient from the ALF, 

the discharge must be done in accordance with the facility’s written policies 

and the recipient or recipient’s designated representative or guardian must be 

given appropriate notice in accordance with Chapter 58A-5, F.A.C. 

Termination of Services 

Introduction 

Recipients may be terminated from the ALE waiver. Case managers 

determine when to terminate a recipient from ALE services. Upon 

termination, the case manager must immediately cancel all waiver services 

being provided to the recipient. The case manager must also notify the 

recipient or the recipient’s designated representative or guardian, the ALF, 

the local DCF office, and the ALE waiver specialist of the recipient’s waiver 

termination. ALE recipients must be given a written 10-day advance notice of 

termination including their right to request a fair hearing. 

July 2001 5-18



Termination of Services, continued 

Reasons For 

Termination 

A recipient who is terminated from ALE services for any one of the following 

reasons must be given a fair hearing notice: 

• Loss of Medicaid eligibility; 

• The recipient’s physical condition no longer meets functional criteria; 

• The recipient moved to a non-waiver setting; 

• The recipient was placed in a nursing facility; 

• The recipient elected to stop ALE services; 

• The recipient refused to comply with the plan of care; and, 

• The recipient would not accept treatment from any of the available 

enrolled providers. 

DOEA Grievance 

Procedure 

ALE waiver consumers can file a grievance with DOEA concerning any 

action taken by DOEA or the DOEA service provider network. Consumers 

should contact their case managers for assistance with their grievance. Case 

managers must assist the consumer or the designated representative with 

preparation and presentation of the grievance. Participation in the DOEA 

grievance process does not affect a consumer’s right to a fair hearing. 

Right To A Fair 

Hearing 

An ALE consumer has the right to appeal any action taken by the ALF, 

AHCA, DOEA or DCF that adversely affects the recipient’s receipt of 

services. 

Note: See Part II, Appendix G for details on how to access the fair hearing 

process. 

July 2001 5-19

Overview 



PART II 

CHAPTER 6 


PROCEDURE CODES AND FEES 

Introduction 

This chapter provides and describes the procedure codes and approved fees 

for assisted living for the elderly (ALE) waiver services. 

In this Chapter 


TOPIC 

PAGE 

Reimbursement Information 6-1 

Appendix F: Procedure Code Table and Fees F-1 

Appendix G: Appeal Rights and Fair Hearing Process G-1 

Reimbursement Information 

Introduction 

Medicaid reimburses for home and community based waiver procedure codes 

based on the Centers for Medicare and Medicaid Services (CMS) Common 

Procedure Coding System (HCPCS), Level III procedure codes and locally 

assigned codes that have been approved by HCFA. Locally assigned codes 

are identified by a “W” prefix. 

Medicaid 

Reimbursement 

Claim Form 

ALE waiver services are billed on the Non-Institutional 081 claim form. 

Note: See the Medicaid Provider Reimbursement Handbook, Non- 

Institutional 081, for specific procedures for submitting claims for payment. 

July 2001 6-1




Procedure Code 

Table 

ALE waiver providers may bill for three waiver services and one state plan 

service provided in their facilities. The procedure code for each service is 

found in Appendix F of this chapter. Each service and its components have 

been explained in Chapter 5 of this handbook. The table gives: 

• The procedure code associated with the service; 

• The name of the service; and 

• The maximum fee that Medicaid will reimburse for the service. 


Reimbursement 

Case management activities are paid on a fixed monthly rate. Reimbursement 

will be made if case management activities were provided for a recipient for any 

portion of the month. Any of the following activities constitute case 

management: 

• Assisting with a recipient’s facility placement or enrollment into the ALE 

waiver; 

• Conducting an assessment or reassessment of service needs; 

• Developing or reviewing a care plan, including arrangements for service 

delivery and referral activities; 

• Conducting a monitoring visit for provision of services or to assess the 

quality of services being rendered; 

• Advocacy or legal related tasks such as working with adult protective 

services, court officials or other investigators on behalf of an eligible 

recipient; 

• Time spent recording activities in the recipient’s case record, telephone 

time or travel time associated with any of the above case management 

activities; and 

• Coordinating hospice, Medicaid state plan and Medicare services with the 

hospice coordinator for ALE consumers electing to receive those services. 

July 2001 6-2




Billing for Case 

Management 

ALE case management services are billed once a month. The date of service 

(DOS) is always the last day of the month for which reimbursement is 

requested. However, if the recipient is admitted to a hospital or a nursing 

facility, the DOS must be the day before the recipient’s admission in order for 

case management to be reimbursed. 

Incontinence 

Supplies Service 

This service is billed once a month using the last day of the month for which 

reimbursement is being requested. The total billing should represent the value 

of those incontinence supplies used by the waiver consumer. Individual waiver 

consumer supplies must be maintained in separate locations and ALE providers 

must keep accurate monthly records of supplies used by individual waiver 

consumers. However, if the recipient is admitted to a hospital or a nursing 

facility, the date of service (DOS) must be the day before the recipient’s 

admission in order for incontinence supplies to be reimbursed. 


Service Component 

Reimbursement 

The assisted living service components are reimbursed at a single per diem rate. 

Reimbursement will not be made for any continuous 24-hour period that the 

recipient is temporarily absent from the facility. 

Billing for Assisted 

Living Service and 

ACS Components 

Assisted living service components and assistive care service components are 

reimbursed by the number of days (i.e., units) the recipient resides in the facility 

while enrolled in the ALE waiver. The total number of units is billed once a 

month using the last day of the month for which reimbursement is requested as 

the date of service (DOS). The billing method should be consistent, preferably 

once per month. However, if the recipient is admitted to a hospital or a nursing 

facility, the last DOS must be the day before the recipient’s admission. 

July 2001 6-3




Billing for ACS and 


Waiver Services 

Facilities participating in the ALE Waiver are required to bill Medicaid for both 

the ACS state plan service and the ALE waiver services for some recipients. 

Waiver Daily Rate Calculation Worksheet 

Instructions for Worksheet 

1. Insert the number of days in the month on Line A 

2. Calculate the Maximum Waiver and ACS for the Month 

(Lines C and D) 

3. Perform the calculations from Line F through Line L to obtain 

the daily waiver payment (L) to bill for the days the recipient received 

services in the facility. 

4. If Line I is “0” (Zero), do not bill for ACS. 

A. Number of Days in the Month 

B. Maximum Daily Waiver Rate $28.00 

C. Maximum Waiver for the Month: A times B 

D. Assistive Care Service Daily Rate $9.28 

E. ACS for the Month: A times D 

F. Is Resident Income Greater than $716.00 and less than 

$770.00 

If YES, add C plus G and Subtract $54.00 

IF NO, add C plus $716.00 

G. Method I 

Recipient Income: Insert Income 

Social Security: _________ 

OSS (State Subsidy): _________ 

Other (Income, if any)_________ 

Total Income: __________ 

H Subtract G from F 

I. Is recipient Income (G) more than $716.00 

If Yes, Insert “0” (Zero). 

If No, Insert ACS for the month (E) 

J. Subtract I from H 

K Add J plus $54.00 

L. Daily Waiver Rate: Divide K by A 

Method II 

(From Notice of Case Action) 

Needs Allowance: ________ 

Pat. Resp.: ________ 

Total Income _________ 

July 2001 6-4




Billing for ACS and 

Waiver Services, 

continued 

ALE waiver recipients with incomes up to $716.00 per month are eligible for 

ACS and ALE waiver payments. 

The ALE waiver facility reimbursement under the waiver program is $1,500.00 

for a 28 day month, $1,556.00 for a 30 day month, and $1,584.00 for a 31 

day month. 

Daily Billing for 


Waiver and State 

Plan Service 

Components 

ALE waiver recipients must be present in the ALF for some period each day 

that is billed for assisted living services. However, no billing is permitted for 

partial days of service. 

When the ALE resident is transferring between two ALE assisted living 

facilities, the discharging facility may not bill for the day of discharge and the 

admitting facility may bill for the day of admission. 

When the ALE recipient is transferring to either a hospital or nursing home, the 

ALE facility cannot bill for the date of discharge. 

When the ALE resident is returning from a hospital, nursing home stay, or other 

temporary absence, the ALE facility can bill for the date of return. 

Recipient 


As part of the eligibility process, DCF applies a standard formula to calculate a 

financial responsibility, if any, for recipients who receive ALE waiver services. 

The ALF, recipient, and the case manager are notified by DCF using a Notice 

of Case Action form of the recipient’s financial responsibility. This monthly 

amount must be deducted from the total charges for assisted living services 

prior to submitting a claim for reimbursement to Medicaid. 

The ALF is responsible for collecting the financial responsibility from the 

recipient and may establish individual collection methodologies to fit the 

circumstances of each recipient. 

July 2001 6-5



PART II 

APPENDIX F 


PROCEDURE CODE TABLE AND FEES 

CODE DESCRIPTION OF SERVICE UNIT MAXIMUM FEE 

W9655 Case Management Monthly $100 

W9654 Assisted Living Daily $28 

W9656 Incontinence Supplies Monthly $125 

Note: ALE waiver providers can bill for ACS state plan services using Pocedure Code W9657 for 

residents with incomes up to $716.00 per month. The daily reimbursement rate for ACS is $9.28. This 

procedure code can only be used by ALE waiver providers billing on the 081 billing form. 

July 2001 F-1



PART II 

APPENDIX G 

APPEAL RIGHTS AND FAIR HEARING PROCESS 

Fair Hearing Process 


Hearing 

A recipient or applicant has the right to appeal any action taken by the Agency 

for Health Care Administration (AHCA), Department of Elder Affairs (DOEA), 

Department of Children and Families (DCF) or service providers that adversely 

affects the recipient’s receipt of services. 

ALE recipients must be given at least 10 calendar days advance written notice of 

any suspension, reduction, or termination of services or program participation. 

The advance notice must inform the ALE recipient of the right to a fair hearing. 

Where to Apply for 

a Hearing 

Hearing requests must be sent to the DCF, Office of Hearing Appeals (OSIH), 

1317 Winewood Boulevard, Building 5, Room 203, Tallahassee, Florida 

32399-0700. The telephone number is (850) 488-1429. 

How to Request a 

Hearing 

The ALE waiver applicant, recipient, or authorized representative must request a 

hearing within 90 days of the receipt of the written notification of the adverse 

decision. ALE case managers must offer assistance to recipients or applicants 

with the fair hearing process. 

Continuation of 

Benefits 

If the ALE applicant, recipient, or authorized representative requests a fair 

hearing within 10 calendar days of the receipt of the notice of case action or 

denial of service, waiver services must be reinstated at the level prior to the 

adverse action. 

If an ALE applicant or recipient requests a fair hearing and services are 

reinstated to the prior level, the recipient might be requested to repay that 

portion of the benefits that the hearing decision determines to be invalid. The 

recipient must be given written notice of this responsibility. 

July 2001 G-1

Assistive Care Services and Assisted Living for the Frail Elderly Waiver Services 


Fair Hearing Process, continued 

Reinstated Benefits 

Reinstated or continued benefits must not be reduced or terminated prior to the 

final hearing decision unless an additional cause for adverse action occurs while 

the hearing decision is pending and the recipient fails to request a hearing after a 

subsequent notice of adverse action. 

The ALE case manager must inform the recipient or authorized representative in 

writing if benefits are reduced or terminated prior to the hearing decision. 

Notification of Fair 

Hearing Decisions 

The hearing officer must send the applicant, recipient, or the authorized 

representative a copy of the final order. In addition to describing the final 

decision of the hearing, the final order explains: 

• The applicant, recipient, or authorized representative can request a judicial 

review of the decision and 

• The applicant, recipient, or authorized representative must pay the cost of 

any judicial review. 

Time Limit on 

Hearing Decision 

Federal law requires the final hearing decision must be made and communicated 

to all involved parties within 90 calendar days of the hearing request. 

Necessary Actions 

to be Taken When 

Appeal is Granted 

Recipient benefit restoration or increases resulting from the final hearing decision 

must begin within 10 calendar days of the date the local office is notified. Benefit 

increases are effective based on the date specified by the hearings officer. 

July 2001 G-2

Assistive Care Services and Assisted Living for the Elderly Waiver

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