ADULT PROTECTIVE SERVICES


FLORIDA LAW
The Florida Abuse Hotline Information System (FAHIS), a part of the Department of Children & Families, provides a uniform system to receive reports of adult abuse, neglect or exploitation from the entire state. Chapter 415, F.S., requires that any person who has knowledge of or suspects that an elderly person or disabled adult (victim) has been abused, neglected or exploited must report such knowledge or suspicion immediately to FAHIS through the 24 hour, toll-free telephone number 1-800-96ABUSE or
1-800-926-2873.

ADULT PROTECTIVE SERVICES
The Adult Protective Services Program is a system of specialized social services directed toward assisting victims who are unable to manage their own affairs, carry out activities of daily living, or protect themselves from abuse, neglect, or exploitation. Assessment of an individual's need for protective services will be initiated in response to a reported allegation of abuse, neglect, or exploitation. The four components of Adult Protective Services are the following:

• On-site investigation of reports of alleged abuse, neglect or exploitation.
• Determination of immediate risk to the victim and provision of necessary emergency services.
• Evaluation of the need for on-going protective supervision; and
• Provision of on-going protective services.

THE PROTECTIVE INVESTIGATION
Chapter 415, F.S., requires the Department of Children & Families to conduct an investigation of all reports received that allege abuse, neglect, or exploitation. The purpose of the investigation is to determine if there is evidence that a victim has been abused, neglected, or exploited and if assistance is necessary to protect the individual's health and safety. A protective investigator from the Department will make a face-to-face contact with the victim within 24 hours of receiving an abuse, neglect, or exploitation report (excluding Saturdays, Sundays, and legal holidays for an exploitation report). If any person refuses to allow the protective investigator access to the victim, law enforcement may be called to assist. Once access to the victim is obtained, the protective investigator will interview all persons who may have knowledge of the victim's situation, evaluate the information obtained, and make a decision as to whether the reported allegations did or did not occur.
As a part of the investigation, the Department must assess the risk to the victim in the home or facility and take action to protect the victim from harm. To assess risk, the protective investigator considers the severity of the injury or harm to the victim, the physical and mental ability of the victim to protect himself or herself, the prior abuse history of the victim, the physical home environment, and the likelihood that the victim will be harmed in the future.

When a victim is at risk and will not be safe in his/her present living arrangements, the Department may place the victim in a more suitable living arrangement in the least restrictive setting. Placement may be in the home of a relative or friend or a home for elderly persons or disabled adults such as an assisted living facility, adult family-care home, or a nursing home. A victim who is capable of making his/her own decisions must request or consent to placement in order for placement to occur. A victim who is not capable of making this decision, may be removed and placed in a safer environment by the Department.

Any time a victim who is not capable of making a decision is removed an placed, the court must review the reasons for the placement and decide if continued placement is necessary. The Department must petition the court for a hearing within 24 hours of the victim's removal from the home (excluding Saturdays, Sundays and legal holidays). A hearing must then be held within 4 days of the petition. The victim of a report, the victim's spouse, guardian, legal counsel, adult children, and next of kin, have the right to be present at any hearing.

INFORMATION YOU PROVIDE
All information obtained from interviews and other sources will be used to assess the risk to the victim and to classify the report. All information obtained during an investigation is confidential. The information obtained during the investigation can be used as evidence in any court proceedings. The Department is required by law to notify the state attorney and law enforcement of reports of abuse, neglect, or exploitation under certain circumstances.

CONFIRMED PERPETRATOR
The identified perpetrator in a "confirmed report may be disqualified from working with children, elderly persons or disabled adults and subject to a civil penalty of up to $1,000.00.

CRITERIA
The allegations must constitute abuse, neglect, or exploitation as defined in Section 415.102, F.S. Definitions:
a)    "Abuse" means the non-accidental infliction of physical or psychological injury or sexual abuse upon an elderly person or disabled adult by a relative, care giver, or household member, or an action by any of those persons which could reasonably be expected to result in physical or psychological injury or sexual abuse of the victim by any person, Abuse is also the active encouragement of any person by a relative, care giver, or household member to commit an act that inflicts or could reasonably be expected to result in physical or psychological injury.
b)    "Neglect" means the failure or omission on the part of the care giver or elderly person or disabled adult to provide the care, supervision, and services necessary to maintain the physical and mental health of the elderly person or disabled adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well-being of an elderly person or disabled adult. "Neglect" is also the failure of a care giver to make a reasonable effort to protect the victim from abuse, neglect, or exploitation by others.
c)    "Exploitation" means a person who stands in a position of trust and confidence with a disabled adult or elderly person, and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use the funds, assets, or property of the elderly or disabled person for the benefit of someone other than the victim.

    OR

A person who knows or should know that the disabled adult or elderly person lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use the funds and assets, or property of the elderly or disabled person for the benefit of someone other than the victim.

PENALTIES

1. A person required by s.415.103, F.S. to report a case of known or suspected abuse, neglect, or exploitation of an elderly person or disabled adult and who knowingly and willfully fails to do so, or who knowingly and willfully prevents another person from doing so, commits a misdemeanor of the second degree, punishable as provided in s.775.082.
2. A person who knowingly and willfully makes public or discloses any confidential information contained in the central abuse registry and tracking system, or in other computer systems, or in the records of any case of abuse, neglect, or exploitation of an elderly person or disabled adult, except as provided in ss.415.101-113, F.S., commits a misdemeanor of the second degree, punishable as provided in s.775.082 or 775.083, F.S.
3. A person who knowingly and willfully makes a false report or who advises another to make a false report, commits a misdemeanor of the third degree felony as provided in s.775.082 or s.775.083, F.S. The Department of Children & Families may also impose fines for false reporting.

Section 825.102, 103, F.S., provided additional criminal penalties.


   
ADULT PROTECTIVE SERVICES - WHAT IS IT?
The legislature recognizes that there are many in this state who because of age or disability are in need of protective services. It is the intent of legislature to provide for the detection and correction of abuse, neglect, and exploitation through social services and criminal investigations and to establish a program of protective services for all elderly persons or disabled adults in need of them. (Florida Statutes 415.101)

WHAT IS ABUSE?
Abuse means the non-accidental infliction of physical or psychological injury or sexual abuse upon an elderly or disabled adult, by a relative, caregiver, or household member or an action by any of these persons which could reasonably be expected to result in physical or psychological injury or sexual abuse of an elderly or disabled adult. Abuse is also the active encouragement of any person, by a relative, caregiver, or household member to commit an act that inflicts or could reasonably be expected to result in physical or psychological injury.

WHAT IS EXPLOITATION?
Exploitation means a person who stands in a position of trust and confidence with a disable adult or elderly person and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use the funds, assets, or property of the elderly or disabled person for the benefit of someone other than the victim.
OR
A person who knows or should know that the disabled adult or elderly person lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use the funds and assets, or property of elderly or disabled persons for the benefit of someone other than the victim.

WHAT IS NEGLECT?
Neglect means the failure or omission on the part of the caregiver or elderly or disabled adult to provide the care, supervision, and services necessary to maintain the physical and mental health of a disabled or elderly person, including but not limited to food, clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well being of an elderly or disabled person, The term "neglect" also means the failure of a caregiver to make a reasonable effort to protect a disabled or elderly person from abuse, neglect, or exploitation by others. "Neglect" is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of health.

WHO IS ELIGIBLE FOR THESE SERVICES IN FLORIDA?
An elderly person 60 years of age or older who is suffering from the infirmities of aging or other physical, mental, or emotional dysfunctino to the extent that the person is impaired in his/her ability to adequately provide for his/her own care or protection.
A disabled person 18 years of age or older who suffers from a condition of physical or mental incapacitation due to a developmental disability, organic brain damage, or mental illness, or who has one or more physical or mental limitations which substantially restrict his/her ability to perform the normal activities of daily living.

REPORTING OF ABUSE, NEGLECT AND EXPLOITATION?
Florida Statutes mandate any person who knows or has reasonable cause to suspect that an aged person or disabled adult is being abused, neglected or exploited shall immediately report such knowledge or suspicion to the Florida Abuse Hotline Information System on the state wide toll free telephone number

    1-800-96-ABUSE

ADULT PROTECTIVE SERVICES INVESTIGATIONS

Adult protective services investigations will begin within 24 hours of receipt of a report of possible abuse.

At the completion of its investigations, reports will be classified as Unfounded, Closed Without Classification, or Proposed Confirmed.

Referrals will be made to criminal justice agencies, the State Attorney, the Human Rights Advocacy Committee (HRAC), Long Term Care Omsbudsman Council (LTCOC) and the Agency for Health Care Administration (AHCA) as appropriate.

APS staff will evaluate and assess the need for ongoing protective social services emergency removal, protective placement, and other necessary social service supports as deemed necessary and appropriate in such individual situations.

    FLORIDA ABUSE HOTLINE
    INFORMATION SYSTEM
    1-800-96-ABUSE
District Four
5920 Arlington Expressway
Jacksonville, FL 32231-0083

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PLAN AHEAD WITH ADVANCE DIRECTIVES

As you age, there are many decisions which you must make about the future. Planning ahead can help you protect your rights and make informed decisions about your health care, your property and your family. Making clear decisions about your life now, before illness and infirmity diminish your ability, allows you to ensure that your plans and choices will be carried out and can make it easier for your friends and family to help you in medical emergencies. There are several legal instruments which will allow you to plan ahead in Florida. These instruments are collectively called Advance Directives and Florida law contains a comprehensive Advance Directives statute providing an adult with three options for Advance Directives:

• a Living Will
• a Health Care Surrogate Designation
• a Durable Power of Attorney

An individual can execute one, two, or all three forms of Advance Directives. An individual does not have to execute any form of Advance Directives in order to receive health care treatment.

Federal law requires that hospitals and long term care institutions, skilled nursing facilities, must advise patients of the existence of Advance Directives. The law does not require the medical facility to supply or prepare these documents. Therefore, it is important to make your decision about Advance Directives prior to any hospital admission.

HOW CAN I PREPARE ADVANCE DIRECTIVES?
Jacksonville Area Legal Aid (JALA) provides services to elderly persons to assist in preparing Living Wills, Health Care Surrogates, and Durable Power of Attorney documents. These services are free to persons who fall within our eligibility guidelines. Call (904)356-8371 to make an appointment or, if your circumstances are an emergency, come to our office on Monday and Thursday of each week, from 8:30 am to 12:00 noon.

LIVING WILL AND HEALTH CARE SURROGATE
There are two general concepts that apply to both living wills and health care surrogates -- life-prolonging procedure and terminal illness. What is a life-prolonging procedure? A life-prolonging procedure means any medical procedure, treatment, or intervention which:
(1)    Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function; and
(2)    When applied to a patient in a terminal condition, serves only to prolong the process of dying.
The term "life-prolonging procedure" does not include the administration of medication or the performance of a medical procedure that is necessary to provide comfort or to alleviate pain.

WHAT IS A TERMINAL ILLNESS?
A terminal illness is defined as:
(1)    A condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery, and which, without treatment, can be expected to cause death
(2)    A persistent vegetative state characterized by a permanent and irreversible condition of unconsciousness in which there is: 1) the absence of voluntary action or cognitive behavior of any kind; and 2) an inability to communicate or to interact purposefully with the environment
(3)    An end-stage condition; condition caused by injury, disease or illness which has resulted in severe permanent deterioration indicated by incapacity and complete physical dependency, and for which to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective.

In determining whether a medical condition or limitation referred to in an Advance Directive exists, the patient's treating physician and at least one other consulting physician must separately examine the patient. The separate findings must be documented in the patient's medical record and signed by each examining physician before life-prolonging procedures may be withheld or withdrawn.

When you have either a living will or a health care surrogate, the physician and hospital must abide by the wishes expressed in those documents. A health care provider who refuses to comply with your wishes is obligated to make reasonable efforts to transfer you within seven days to another provider who will comply with your wishes. The law does not require a provider to act in a way contrary to his/her moral or ethical beliefs concerning life-prolonging procedures if you are not in an emergency condition, and if you have received written information upon admission informing you of the provider's policy regarding such moral or ethical beliefs. If there are problems with the provider's compliance to the Florida Advance Directive laws, your surrogate or someone on our behalf should see the advise of an attorney.

LIVING WILL
A living will is a document in which you can stipulate the type of life-prolonging medical care, if any, you desire if you become terminally ill and unable to make your own decisions. A living will is a written consent document that you voluntarily execute. The terms of your living will take effect only if you have a terminal illness and, at the time, are unable to express your desires with respect to life-prolonging procedures.

HEALTH CARE SURROGATE
A Health Care Surrogate is a competent adult expressly designated by you to make health care decisions for you if you become unable to make those decisions. A document designating a health care surrogate may also designate an alternate surrogate. If neither the designated surrogate nor the designated alternate surrogate is able or willing to make health care decisions on your behalf, a health care facility may seek the appointment of a proxy. A proxy means a competent adult who you have not chosen to make health care decisions for you, but who, nevertheless, is authorized by the court to make health care decisions for you.

The terms of a Health Care Surrogate Designation take effect whenever your treating physician and another physician conclude that you lack the capacity to make health care decisions for yourself. Unless the document states a time of termination, the designation shall remain in effect.

DURABLE POWER OF ATTORNEY
A Durable Power of Attorney is a signed, dated, and witnessed legal document in which you designate a person as your attorney-in-fact. A Durable Power of Attorney permits the person you have designated to handle all financial and legal matters for you, including banking, real estate matters, government benefits, living arrangements, health care, and many other matters pertinent to your needs. The Durable Power of Attorney must be in writing and must state the relationship of the parties (family or otherwise). It must include the words, "This Durable Power of Attorney shall not be affected by disability of the principal except as provided by statute FS ß709.08" or similar words. The words must clearly show your intent that the power conferred will continue even if you become incompetent. A properly executed Durable Power of Attorney can avoid the necessity of someone seeking a court-appointed guardian to handle your affairs if you become incapable of making decisions for yourself. To revoke a Durable Power of Attorney, this should be done in writing, with two (2) witnesses, notarized and send a copy of the revocation certified mail to your attorney-in-fact.

LAST WILL AND TESTAMENT
A Last Will and Testament, or will, is a written document that disposes of a person's property after his or her death, or a document that revokes or revises another will. A person who writes a will is called a testator. As long as you, as the testator, have the requisite testamentary capacity and do not contravene the law or public policy by the will, you may dispose of property as you desire.

No particular words or phrases are required to make a will operative or effective if it is executed in conformity with the Florida probate law. If it is executed in another state or country, a will is valid under Florida law if it was valid in that state or country at the time of its execution.

TESTAMENTARY CAPACITY - Any person who is 18 or more years of age and who is of sound mind may make a will. You are deemed to have the requisite testamentary capacity if you can understand the nature and extent of the property to be disposed of by will, your relationship to those who would naturally claim the benefits of the will, and the effect of the terms of the will. The fact that a person is mentally weak or has been adjudicated incompetent to handle his or her day-to-day affairs does not mean that person lacks testamentary capacity, if he or she can comprehend matters that relate to the testamentary disposition of his or her property.

EXECUTION OF WILL - The law requires that you, as the testator, place your signature at the end of the will. Your signing of the will, or your acknowledgment that you have previously signed the will or had another sign it for you, must be done in the presence of two witnesses. You do not actually have to write out your name to sign a will. Rather, it is sufficient that you make an "X" or some other mark on the will with the intent that it constitutes your signature thereby demonstrating your assent to the will.
The witnesses must sign the will in the presence of each other and in your presence. The witnesses may sign an attestation clause which is a statement to the effect that they observed the signing of the will. Any person who is competent to be a witness in any legal proceeding may witness the signing of the will.

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GUARDIANSHIP AND SOME ALTERNATIVES

Some people,due to sickness or age may need help from others to take care of themselves and/or their property. In some cases, this is done under the supervision of a judge through guardianship proceedings.

WHAT IS A "GUARDIAN"?
A guardian is someone who is appointed by a judge to make personal decisions for, or manage the property of a person that a judge has determined is legally incompetent.

WHEN IS A PERSON LEGALLY INCOMPETENT?
A person is legally incompetent when a judge determines that the person, due to age(under 18 years), mental illness, retardation, or other physical or mental capacity, is unable to make decisions regarding his care or manage his property.

WHAT STEPS MUST BE TAKEN BEFORE A GUARDIAN IS APPOINTED?
A close relative, or three citizens of the State of Florida who know the person, must file a petition requesting the judge find that the person is legally incompetent. The judge will review a report of a committee of doctors and hold a hearing before deciding whether a person is legally incompetent. The person whose competency is in question has the right to be represented by an attorney at this hearing. Once the judge finds a person to be legally incompetent, a guardian must be appointed.

WHO MAY BE A GUARDIAN?
Any close relative of the incompetent person, or if no relative is available or able to serve, almost any resident of the State of Florida may serve. Anyone who has been convicted of a felony or who is incapable of discharging the duties of guardian cannot be appointed. A person who wishes to act as guardian must file a petition with the judge requesting their appointment as guardian. The judge will consider the wishes of the incompetent person in deciding who shall act as guardian.

WHAT DUTIES DOES A GUARDIAN HAVE?
A guardian must make decisions regarding the care of the incompetent person and/or their property. Each year the guardian must file with the judge a report, summarizing the incompetent person's condition, medical treatment received and whether competency can be restored. The guardian may also be required to file an annual accounting describing all income and expenses in the guardianship estate, and may be required to appear before the judge to answer questions about the guardianship.

WHAT ARE SOME ALTERNATIVES TO GUARDIANSHIP AND WHY SHOULD THEY BE CONSIDERED?
Guardianship requires a judge to declare a person legally incompetent. Once a person is legally incompetent, they lose many rights such as the right to make contracts, the right to vote, or the right to drive. In some cases, guardianship is not necessary because a person's needs can be met through legal alternatives such as a durable family power of attorney, or appointment of a representative payee.

WHAT IS A DURABLE POWER OF ATTORNEY?
A durable power of attorney is a document signed by a person giving permission to an individual to act on their behalf. The person signing the power of attorney must fully understand the meaning of the power of attorney and be competent at the time they sign it.

WHAT IS A REPRESENTATIVE PAYEE?
A representative payee is a person appointed by the Social Security Administration to manage social security or supplemental security benefits for a person who cannot manage their money. A person who wishes to become a representative payee for someone must apply at the local social security office.

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JOINING AN HMO

THINKING OF JOINING A MEDICARE HMO? - WHAT TO ASK
The answers to each of the following questions should be considered carefully before making a decision to choose a Medicare HMO.
Know the Costs

• How much does it cost each month to belong?
• What co-payments or out-of-pocket expenses will I have?
• Does the HMO pay for the cost of any or all prescription drugs? If yes, how much will be paid each month?
• How much will I have to pay to see a physician who is not in the HMO?

Know What's Covered:

• If I join an HMO, will I lose any of my Medicare benefits? (Ask for a list of benefits and services.)
• To what extent are specific needs such as eyeglasses, mental and home health care, hospice, medical equipment and rehabilitation covered?
• Are there any limits to the number and type of visits per year or the number and type of diagnostic procedures? And what about hospitalization limits?
• If I develop a serious, nonlife-threatening illness in another community, state or country, will I be covered?
• Do I need preapproval for non-emergency hospital or outpatient care?
• What is paid for if I need transportation in order to see a doctor or have a prescription filled?

Know What is Available in an Emergency

• Is 24-hour emergency care available? If yes, where must I go to receive the care?
• Who pays if, in an emergency, I am taken to the nearest hospital which is not under contract with the HMO and I require extensive treatment?
• Do I need prior approval for emergency treatment?
• Are ambulance services covered?
• What must I do when the HMO offices are closed and I need to see a physician?

Know What Choices You Have

• Can I continue to see my current physician, or must I go to a physician in the HMO?
• If I am assigned a physician, will I be allowed to change physicians if I don't like the one chosen for me?
• Will I be seen and treated each time by the same physician?
• Will I always be able to see a physician, or will routine care be handled by nurse practitioners, physician's assistants or other physician extenders?
• What if I want to be seen by a physician rather than by a physician extender?
• How many physicians are in the network? (Ask for a list of doctors in the HMO.)
• Do I have to use only the physicians listed in your agreement?
• What happens if my physician leaves the HMO?
• Where must I go for care if I have a serious or chronic health problem requiring the attention of a specialist?
• If the particular specialist I need is not affiliated with the HMO, is my care covered?
• If I want a second opinion from a physician outside the plan, will the HMO pay for it?
• How many locations for routine medical care does each plan have in my community? Where are they located? Ill I have a choice of locations? (Ask for a list of locations.)
• Can I see a physician immediately? How long must I wait for an appointment?
• Will I be able to get prescriptions at any drugstore or pharmacy, or will have to pick them up at certain selected pharmacies?
• What hospitals and nursing facilities may I visit and still have the expenses paid for by the HMO?

Know How it Works

• Does the plan offer financial incentives to physicians and hospitals for shortening a patient's hospital stay or reducing the level of other health care services?
• Can I be dropped from the plan involuntarily? Under what circumstances?
• If I become dissatisfied with an HMO, how long will it take before I can go back to the Medicare coverage only?
• How do I file a complaint if I am not satisfied with the care I am receiving?

For more information regarding Medicare health care programs call or write:

SHINE
Serving Health Insurance Needs of Elders
Florida Department of Elder Affairs
4040 Esplanade Avenue, Suite 152
Tallahassee, Florida 32399-7000
(904)414-2060
 
or
  
Area Agency on Aging
1(800) 262-2243   

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MEDICAID MANAGED CARE


WHAT IS MEDICAID MANAGED CARE?
Florida law requires that most people getting Medicaid be in "managed care." This means that most of your health care services must be provided through a managed care plan. Medicaid recipients have three types of managed care plans they can choose from:

• MediPass
• Medicaid health maintenance organizations (HMOs)
• Children's Medical Services (CMS)     Network

WHAT IS THE MEDIPASS PROGRAM?
MediPass is a statewide program made up of family or primary care doctors. They are paid by the state a small monthly "case management fee" for each of their enrollees as well as fees for services provided. Sometimes a specialty doctor can serve as a MediPass doctor. This may be done for someone who has a disability and regularly sees a specialist. The local Medicaid office can help with this. You must see your MediPass doctor for most of your medical needs, including any referral to specialists or the hospital. Your MediPass doctor can refer you to any other Medicaid provider.

WHAT IS A MEDICAID HMO?
A Medicaid HMO is a health insurance company that is paid a flat monthly fee by the state for each enrolled Medicaid recipient. Medicaid HMOs are available in most, but not all counties in Florida.You must see your HMO primary care doctor for most of your medical needs, including any referral to specialists or the hospital. Your doctor can only refer you to other doctors within the HMO's network.

WHAT IS THE CMS NETWORK?
The CMS Network is a statewide managed care plan for children with special health care needs. This plan provides care through doctors and other providers who are specially qualified. A child must meet certain medical eligibility criteria to qualify for this program.

HOW DO I CHOOSE A PLAN?
You will be sent written information and invited to call the Medicaid Options Helpline, 1-888-367-6554, for more information on each of these programs.
Ask your current doctor if they are part of a managed care plan. If you want to keep your doctor make sure your plan choice allows you to do this. Before you sign up, find out what doctors are in the plan, where they are located and if they speak your native language.

HOW DO I GET OUT OF MEDICAID HMO OR MEDIPASS?
If you are a new Medicaid recipient, you will be able to change your health plan for any reason during the first 90 days of your enrollment. You can do this by calling the Medicaid Options Helpline. After you stay in the plan for 90 days, you will only be able to change plans nine (9) months later, during your 60 day "open enrollment" period. After the 60 days, you will be locked into your plan for 12 months until your next open enrollment period. However, if you have a "good cause" reason to change plans before your open enrollment period, you can request this at any time through the Medicaid Options Helpline. If your request is denied, you can ask for a fair hearing as described below. If you get health care services outside of your health plan before the effective date of your disenrollment, Medicaid will not pay for these services. You will receive written notice of the date your disenrollment from the plan is effective. If you are a current Medicaid recipient and you decide to change your health plan, the same disenrollment rules for new recipients, described above, will apply to you.

HOW DO I CHANGE MY DOCTOR?
You do not need to change health plans if you just want to change doctors. You may request a change of your primary care doctor within your health plan at any time. If you are in MediPass, you contact the local Medicaid office. If you are in any HMO, you contact the HMO's Member Services office.

WHAT CAN I DO IF I HAVE A COMPLAINT OR PROBLEM WITH MEDICAID MANAGED CARE?
If you have a problem with your care, you have a right to complain. You can complain about problems such as:

• Not being able to get an appointment
• Not getting the services you need
• Not being able to change doctors or health plans
• Difficulty speaking with your doctor or HMO due to language differences
• Constantly busy phone lines
• No one answering the phone
  
  If you cannot resolve your complaint through a phone call and you are in a Medicaid HMO, write to the "grievance coordinator" at the HMO. Describe your complaint, date the letter, and keep a copy for yourself.
  
  If you have an HMO quality of care complaint, call 1-800-266-1062. Again, make a note of who you spoke to and the date of your complaint.
  
  If you have a problem with the MediPass program you should contact your local Medicaid office. If the problem cannot be resolved through a phone call, you should write to the MediPass "grievance coordinator" and keep a copy of your dated complaint letter.
  
  If you want to disenroll from a plan, you must call the Medicaid Options Helpline at 1-888-367-6554.
  
  For any managed care problem that can't be resolved, you can also request a Medicaid fair hearing. To do this, you must write or call the Office of Appeal Hearings, Department of Children and Families, Building 1, Room 309, 1317 Winewood Boulevard, Tallahassee, FL 32399-0700, (850)488-1429.
  
  If you need help with a managed care grievance or fair hearing, you can contact your local legal services or legal aid program.

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ARE YOU IN A MEDICAID HMO? THESE ARE YOUR RIGHTS

IF YOU RECEIVE MEDICAID AND ARE ENROLLED IN A MEDICAID PREPAID PLAN (ALSO CALLED HEALTH MAINTENANCE ORGANIZATIONS, OR HMOs), YOU HAVE CERTAIN RIGHTS WHICH ARE DISCUSSED BELOW:

Q.Do I have a right to complain if I am unhappy with the care I receive at my HMO, for instance, if my HMO denies me services, limits services, or unreasonably delays my medical care?

A.Yes. You have a right to complain both to the HMO and to the Medicaid Program. (The Medicaid Program used to be part of HRS but is now part of the new Agency for Health Care Administration [AHCA].)

Q.How do I make a complaint to my HMO?

A.You should call or write to the "Grievance Coordinator" for the HMO. If you write, state in your letter that you are filing a grievance. Keep a copy of your letter for your records. It is better to complain in writing than to complain by phone.

Q.Do I have a right to complain if the HMO refuses to pay for emergency care?

A.Yes. You should always try to follow the HMOs rules about getting emergency care outside of the HMO. HMOs generally require that you call and get prior authorization to use the emergency room. However, if you are unable to do so, and the HMO refuses to pay for the emergency room bill, you have a right to disagree with this by filing a grievance with the HMO.

Q.Can I also make a complaint against my HMO with the Medicaid office?

A.Yes. You can do this by calling the Medicaid office in Jacksonville at 353-2100 or 1-800-273-5880.

Q.Do I have a right to see a specialist at the HMO?

A.Yes, if it is medically necessary. You can ask for a referral and file a grievance if you do not get the referral.

Q.Do I have a right to transportation assistance from my HMO?

A.Yes.

Q.If I no longer want to be in the HMO, do I have a right to get out?

A.Yes. This is called disenrollment.

Q.How do I disenroll, and how long does it take?

A.The HMO cannot restrict your right to disenroll in any way. For example, the HMO cannot require that you come into the clinic in person in order to disenroll. The HMO must honor any signed request for disenrollment. Therefore, you only need to send them a letter, with your signature, requesting that you be disenrolled. It is best to keep a copy for yourself and to send it by certified mail, return receipt requested.

Q.Do I have a right to a second opinion if I disagree with how the HMO is handling my medical problem, and who pays for the second opinion?

A.Yes, you have this right. Depending on the doctor who is chosen, either the HMO pays 60% and you pay 40%, or you pay for the doctor up to a certain amount.

Q.What should I do if the HMO and/or the Medicaid office does not take care of my complaint?

A.You should contact Jacksonville Area Legal Aid, Inc. for assistance.

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MEDICAID

WHAT IS MEDICAID?
The Florida Medicaid program helps low income people with medical needs.

WHO IS ELIGIBLE FOR MEDICAID?
Not everyone who is poor can get Medicaid. You must be low income and fit into certain groups. The following are the major groups which can get Medicaid:

• People getting cash assistance under the WAGES program
• People getting Supplemental Security Income (SSI)
• People who are elderly and people with disabilities
• Pregnant women
• Children and their parents or caretaker relatives
• Families with an unemployed parent
• Some immigrants
  

HOW DO YOU APPLY FOR SERVICES?
You apply at your local Department of Children and Family Services (DCAF) office. DCAF must act on your application within 45 days. However, for applications based on disability DCAF has 90 days to make a decision. If you just want to apply for your children you can mail in a KidCare application. You can get a KidCare application from your local DCAF office, county health department or by calling 1-800-540-5437.

HOW DOES MEDICAID WORK?
Most medical providers are required to be in a managed care plan.
People on Medicaid get a ;Medicaid card which they must show to their doctor or other medical provider. Not all doctors take Medicaid, so someone getting Medicaid must find doctors willing to accept it.
If the doctor accepts Medicaid, they cannot charge the person on Medicaid. However, for some services, like doctor visits, small co-payments may be charged. The doctor cannot refuse to treat someone on Medicaid because they are unable to pay the co-payment.

WHAT SERVICES DOES MEDICAID COVER?
Medicaid pays for many kinds of medical care including:

• Hospital services
• Doctor visits
• Nursing home services
• Mental health services
• Prescription medications
• Medical equipment
• Transportation
• Children on Medicaid can get even more services including:
      Health screening
      Shots
      Full dental care
      Therapies

WHAT CAN YOU DO IF YOU HAVE A MEDICAID PROBLEM?
Call the local Medicaid office for help if:

• You have a question about services
• You can't find a doctor or get transportation to the doctor
• You get a medical bill that Medicaid should have covered.
• You have the right to a fair hearing before a hearing officer if:
  Your Medicaid application is not acted on within 45 days, or 90 days for applications based on disability, or your application is denied. 
• Your Medicaid benefits are incorrectly denied, stopped or reduced.
• You can request a fair hearing by calling or writing to:
  Office of Appeal Hearings
  Department of Children and Families, Building 1, Room 309,
  1317 Winewood Boulevard
  Tallahassee, FL 32399-0700.
• If you have questions about Medicaid or need help with a fair hearing, you can contact your local legal services or legal aid program.

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MEDICAID RIGHTS

A SPOUSE IN A NURSING HOME: YOUR FLORIDA MEDICAID RIGHTS INTRODUCTION

• If your husband or wife is going to a nursing home, you are probably worried about the cost.
• Who will pay the bills?
• How will you live?
• Will you have to sell your home?
• This pamphlet answers these questions and explains the complicated provisions under which financial aid in the form of Medicaid may be available for nursing home care. The pamphlet does not take the place of face-to-face legal or financial advice. Medicaid laws change fast.
• If you need additional information, there are numerous agencies that may help you, including your local Legal Service or Legal Aid office.
  

WHAT IS MEDICAID?

• Medicaid is a program run by the federal and state government.
• It pays for the medical care of persons who cannot afford to pay it themselves.
• Medicaid pays for nursing home care in certain cases. 
• It may pay for your spouse's nursing home care. 
• Your spouse may be eligible for Medicaid if your doctor determines that your spouse has to be in a nursing home and your spouse is eligible because 1) he or she is already receiving SSI or welfare benefits or 2) he or she is over 65, blind or disabled and has little income and assets.

HOW MUCH INCOME CAN MY SPOUSE HAVE TO GET MEDICAID?

• To get Medicaid to pay for nursing home care, your spouse may not have a monthly income of more than 300% of the SSI rate for a single person. 
• That comes to $1,536 a month effective January 1, 2000. This figure will go up every year.
• If your income exceeds the Medicaid income limit, an income trust can be established in order to qualify for Medicaid.

WILL MEDICAID PAY THE ENTIRE NURSING HOME BILL OR DOES MY SPOUSE HAVE TO PAY SOMETHING?

• Your spouse may have to pay something.
• The state of Florida has a complicated formula for figuring the amount Medicaid recipients have to pay toward their nursing home care.
  

I RELY ON MY SPOUSE'S INCOME. DO I GET TO KEEP ANY OF IT?

• Yes. You get to keep a minimum monthly maintenance allowance. That comes to $1,383 a month, effective July 1, 1999. This amount will go up every year.
• If you have high shelter costs like rent, mortgage, taxes and insurance, you may be able to keep even more.

DOES MY SPOUSE GET TO KEEP ANY MONEY?

• Yes, at present, Medicaid recipients in nursing homes get to keep $35 for personal needs.

DO THESE RULES APPLY TO A SPOUSE ALREADY IN A NURSING HOME?

• Yes. These rules became effective in September 1989. Everyone who has a spouse in a nursing home should make sure both they and their spouse are getting all the income they can.

MY SPOUSE AND I HAVE MONEY IN THE BANK AND OTHER ASSETS. DO ALL OUR ASSETS HAVE TO GO TO THE NURSING HOME?

• No. You can keep up to $81,960 worth of assets, effective January 1, 1999. This amount includes the nursing home spouse's $2,000 asset limit. This figure will change each year. 
• Some things won't be counted toward the asset limit.
• For example, the following generally are not counted:
  Your home
  Your household and personal property
  One car
  Life insurance
  Burial fund
  Property you need for self-support

WHAT IF WE HAVE TOO MANY ASSETS WHEN MY SPOUSE GOES INTO THE NURSING HOME?

• Assets are looked at the time you apply for Medicaid. If the two of you have too many assets your spouse will not be eligible for Medicaid.

IF WE HAVE TOO MUCH MONEY IN THE BANK OR OTHER ASSETS ON THE DAY MY SPOUSE IS ADMITTED TO THE NURSING HOME, IS THERE ANYTHING WE CAN DO TO MAKE MY SPOUSE ELIGIBLE IN THE FUTURE?

• Yes. You and your spouse can pay off your mortgage or buy things like household furnishings. You can spend your money today for or buy assets that do not count toward your asset limit. When your assets are below the limit, your spouse will be eligible.

WHAT IF I INHERIT MONEY, WIN A BIG PRIZE, OR SOMEHOW GET MORE ASSETS AFTER MY SPOUSE GETS MEDICAID AND GOES INTO A NURSING HOME?

• You get to keep the new asset. It will not affect your spouse's Medicaid eligibility.

I THINK MY SPOUSE HAS TOO MANY ASSETS TO GET MEDICAID FOR THE NURSING HOME. CAN WE GIVE THE ASSETS AWAY IN ORDER TO BECOME ELIGIBLE FOR MEDICAID?

• It depends. In some cases, persons will be penalized for transferring assets to get Medicaid. The general rule is that persons who transfer or give away an asset for less than it is worth, within 36 months of filing an application for Medicaid will be ineligible for nursing home Medicaid for a period of time. 
• The length of the ineligibility period depends upon the value of the asset you gave away.

WHAT ARE THE EXCEPTIONS?

• There is no penalty if your spouse transfers the home to you, any of his minor or disabled children, a sibling who already has an equity interest in the home, or a child who lived with and took care of your spouse in the home for at least two years before going into the nursing home. Other assets are treated differently.
• With any other countable asset, no penalties will apply if your spouse transfers the asset to you or to someone who will use it for your benefit, or to any of his children who are blind or disabled or their spouses.

WHAT HAPPENS IF WE TRANSFER AN ASSET FOR LESS THAN ITS WORTH AND NO EXCEPTIONS APPLY?

• Both you and your spouse may be ineligible for nursing home Medicaid for a period of time. However, neither you nor your spouse will be penalized at all if there is a valid reason for the transfer. 
• There are three such valid reasons. First, the transfer was made for a reason other than to make your spouse eligible for Medicaid. Second, you meant to transfer the asset for fair market value. Third, denying nursing home Medicaid works an undue hardship.
      
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