Long Term Services and Supports (LTSS) – Florida

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WellCare of Florida

Staywell of Florida

Long Term Services and Supports (LTSS) – Florida

Policy Number: HS-500

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medic aid Serv ices (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

DISCLAIMER

The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, contract language, etc. take precedence over the CCG (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Cov erage Determinations [LCDs] or other published documents). The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of C ov erage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be us ed as treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations, and any state-specif ic Medic aid mandates. Links are current at time of approval by the Medical Policy Committee (MPC) and are subject to change. Lines of business are also subjec t t o c hange without notice and are noted on www.wellcare.com. Guidelines are also available on the site by selecting the Provider tab, then “Tools” and “Clinical Guidelines”.

BACKGROUND

Long-term services and supports (LTSS) are services and supports used by Members of all ages with functional limitations and chronic illnesses. LTSS helps those needing assistance to perform routine daily activities (e.g., bathing, dressing, meal preparation, administering medications). Types of LTSS benefits are noted below. To determine eligibility, Members should check their benefits package.

Medicaid is the primary payer across the nation for LTSS. Medicaid allows for the coverage of these services through several vehicles and over a continuum of settings, ranging from institutional care to community based long- term services and supports. CMS is working in partnership with states, consumers and advocates, providers and other stakeholders to create a sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control and access to a full array of quality services that assure optimal

outcomes, such as independence, health and quality of life. The programs and partnerships contained in this section are aimed at achieving a system that is: ¹

• Person-Driven: Allows older people, and those with disabilities and/or chronic illness the opportunity to decide where and with whom they live, to have control over the services they receive and who provides the services, to work and earn money, and to inclusion of friends/supports to help participate in community life.

• Inclusive: Encourages and supports people to live where they want to live with access to a full array of quality services and supports in the community.

• Effective and Accountable: Offers high quality services that improve quality of life. Accountability and responsibility is shared between public and private partners and includes personal accountability and planning for long-term care needs, including greater use and awareness of private sources of funding.

• Sustainable and Efficient: Achieves economy and efficiency by coordinating and managing a package of services paid that are appropriate for the beneficiary and paid for by the appropriate party.

• Coordinated and Transparent: Coordinates services from various funding streams to provide a

coordinated, seamless package of supports, and makes effective use of health information technology to

Clinical Coverage Guideline page 1

provide transparent information to consumers, providers and payers.

• Culturally Competent: Provides accessible information and services that take into account people's cultural and linguistic needs.

Approximately 11 million people in the United States receive LTSS; almost 60% are elderly and over 40% are age 18 to 65 with a physical and/or developmental disability. LTSS helps a Member achieve more independence as they may be able to continue living at home or another desired setting. The need for LTSS is expected to grow as the number of those over age 65 will double by 2050 – 70% of those will utilize LTSS at some point. The need for LTSS quadruples for those over age 85.²

Under the Statewide Medicaid Managed Care Long-term Care (LTC) program, managed care plans (LTC plans) are required to provide an array of home and community-based services that enable enrollees to live in the community and to avoid institutionalization. ³

Florida Medicaid LTC plans cover services that are:³

• Consistent with the type, amount, duration, frequency, and scope of services specified in an enrollee’s authorized plan of care;

• Provided in accordance with a goal in the enrollee’s plan of care

• Intended to enable the enrollee to reside in the most appropriate and least restrictive setting Florida Medicaid LTC plans cover services that meet the following: ³

• Are determined medically necessary, as defined in this rule

• Do not duplicate another service

• Meet the criteria as specified in this policy POSITION STATEMENT

Applicable To:

Medicaid – Florida Medicare – Florida Exclusions ³

The State of Florida LTC program benefit does not include coverage for the following:

• Adaptations which add to the total square footage of the home.

• Food or the cost of meals when provided other than through home-delivered meal services.

• Personal emergency response system services for enrollees who do not live alone or who are not home alone for significant parts of the day and would not otherwise require high intensity or constant supervision.

• Respite care services for enrollees residing in a nursing facility or an assisted living facility (ALF).

• Services provided to enrollees in a:

o ˗ Hospital licensed pursuant to Chapter 395, F.S.

o ˗ Group home licensed pursuant to Chapters 393, 394, or 397, F.S.

o ˗ State mental health hospital licensed pursuant to Chapter 395, F.S.

o ˗ Intermediate care facility for individuals with intellectual disabilities licensed pursuant to Chapter 400, F.S.

• Room and board payments to ALFs or adult family care homes.

• Transportation services when transportation is available to the enrollee without charge from family, neighbors, friends, or community agencies.

Clinical Coverage Guideline page 2

Original Effective Date: 7/30/2019 - Revised: 4/16/2020

PRO_55321E Internal/State Approved 07272020 FL0PROWEB55321E_0000

Coverage ³

Services are considered medically necessary when the following criteria are met:

1. Member must meet all medical necessity as outlined by the Florida Medicaid Managed Care Long-term Care Program Coverage Policy:

a. Nursing facility services and mixed services must meet the medical necessity criteria defined in Rule 59G-1.010, F.A.C.

b. All other LTC supportive services must meet all of the following:

I. 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

II. 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 statewide

III. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider

IV. And, one of the following:

i. Enable the enrollee to maintain or regain functional capacity; or

Enable the enrollee to have access to the benefits of community living, to achieve person-centered goals, and to live and work in the setting of his or her choice.

2. Member must be enrolled in the State of Florida LTC program on the date of service; AND

3. Member is a State of Florida Medicaid recipient that requires medically necessary LTC services; AND 4. Member has a nursing facility level of care determined by the CARES program; AND

5. Authorization is for one of the following services:

c. Adult Day Health Care;

d. Assisted Living;

e. Assistive Care Services;

f. Attendant Nursing Care;

g. Behavioral Management;

h. Care Coordination / Case Management;

i. Caregiver Training;

j. Companion Care;

k. Home Accessibility / Adaptation Services;

l. Home Delivered Meals;

m. Homemaker Services;

n. Hospice;

o. Intermittent and Skilled Nursing;

p. Medical Equipment and Supplies;

q. Medication Administration;

r. Medication Management;

s. Nursing Facility Services;

t. Nutritional Assessment / Risk Reduction Services;

u. Occupational Therapy;

v. Personal Care;

w. Personal Emergency Response Systems (PERS);

x. Physical Therapy;

y. Respiratory Therapy;

z. Speech Therapy;

aa.

Respite Care;

bb. Transportation.

CODING

Covered CPT Codes

97802 Nutritional assessment/risk reduction services

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Clinical Coverage Guideline page 4

Original Effective Date: 7/30/2019 - Revised: 4/16/2020

PRO_55321E Internal/State Approved 07272020 FL0PROWEB55321E_0000

97803 Occupational therapy, age 21 and older 97110 Physical therapy, age 21 and older 97537 Caregiver training individual

99504 Respiratory therapy, treatment mechanical vent care 99503 Respiratory therapy, treatment regular, age 21 and older 92507 Speech therapy, age 21 and older

Covered HCPCS Codes

S5135 Adult companion care S5100 Adult day health care T2030 Assisted living service T1020 Assistive care services S5125 Attendant care

H2020 Behavioral management, assessment H2019 Behavioral management, intervention S5100 Caregiver training group

G9002 Case Management

S5165 Home Accessibility adaptation services S5170 Home delivered meals

S5130 Homemaker services

G9004 Homemaker services pest control, initial visit G9005 Homemaker services pest control, maintenance T1002 HN Intermittent and skilled nursing, BSN

T1003 Intermittent and skilled nursing, LPN (up to 15 min) T1002 Intermittent and skilled nursing, RN (up to 15 min)

S5199 Medical Equipment and Supplies, Personal Care , Item regular miscellaneous Medical Equipment and Supplies, Personal Care, Item for Trach Miscellaneous S5199 AU Medical Equipment and Supplies, Personal Care

E1399 Medical Equipment and Supplies, Specialized, Medical Equipment Regular Miscellaneous E1399 AU Medical equipment and supplies, specialized medical equipment for Trach Misc

T1503 HN Medication administration, administration of medication, other than oral and /or injectable by BSN T1503 TD Medication administration, administration of medication, other than oral and /or injectable by RN T1503 TE Medication administration, administration of medication, other than oral and/or injectable by LPN

Medication administration, administration of oral, intramuscular, and/or subcutaneous T1502 HN medication by BSN

Medication administration, administration of oral, intramuscular, and/or subcutaneous T1502 TD medication by RN

Medication administration, administration of oral, intramuscular, and/or subcutaneous T1502 TE medication by LPN

T2010 HN Medication management, comprehensive medication services BSN T2010 TE Medication management, comprehensive medication services LPN T2010 TD Medication management, comprehensive medication services RN T1019 Personal Care

S5160 Personal emergency response team installation

S5161 Personal emergency response team monthly maintenance S5180 Respiratory therapy, evaluation, age 21 and older

T1005 Respite in facility S5150 Respite in home

Covered ICD-10 Codes: All applicable codes

Coding information is provided for informational purposes only. The inclusion or omission of a CPT, HCPCS, or ICD-10 code does not imply member coverage or provider reimbursement. Consult the member's benefits that are in place at time of service to determine coverage (or non- coverage) as well as applicable federal / state laws.

page 5 REFERENCES

1. Long Term Services and Supports. Medicaid Web site. https://www.medicaid.gov/medicaid/ltss/index.html Accessed January 11, 2018.

2. NCQA Standards and Guidelines for the Accreditation of Case Management for Long-Term Services and SupportsPrograms. Effective January 1, 2017. Accessed January 11, 2018.

3. Statewide Medicaid Managed Care Long-term Care Program Coverage Policy (59G-4.192). Agency for Health Care Administration Web site. Published March 2017. https://ahca.myflorida.com/medicaid/review/Specific/59G-4.192_LTC_Program_Policy.pdf . Accessed July 14, 2019.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

4/16/2020 • Approved by MPC. Added medical necessity definition from FL Medicaid handbook.

7/30/2019 • Approved by MPC. New.

Clinical Coverage Guideline