Action - Denial or limited authorization of a requested service or payment to such service; reduction, suspension, or termination of a previously authorized service; or failure of a plan to timely provide services or respond to a grievance or appeal.
Acute Care Services - Short-term medical treatment that may include, but is not limited to, community behavioral health, dental, hearing, home health, independent laboratory and x-ray, inpatient hospital, outpatient hospital/emergency medical, physician, prescribed drug, vision, or hospice services.
Aging and Disability Resource Center (ADRC) - An agency designated by the Department of Elder Affairs (DOEA) to develop and administer a plan for a broad and coordinated system of services for older and disabled persons.
Centers for Medicare & Medicaid Services (CMS) - The agency within the United States Department of Health & Human Services that provides administration and funding for Medicare, Medicaid and the Children’s Health Insurance Program under the Social Security Act.
Comprehensive Assessment and Review for Long-Term Care Services (CARES) - Florida’s long-term care preadmission screening program for nursing home applicants. CARES helps to identify long-term care needs of individuals and establishes a level of care (medical eligibility) for nursing home and Medicaid waiver applicants.
Department of Children and Families (DCF) - The state agency primarily responsible for deciding Medicaid eligibility. DCF also manages other programs related to abuse and neglect, mental health, substance abuse, homelessness, and other social service programs.
Long-term Care Assessment - An individualized and comprehensive assessment of an individual’s medical, developmental, behavioral, social, financial and environmental status conducted by a qualified individual for the purpose of determining the need for long-term care services.
Medicaid Providers - Hospitals, nursing homes, public health units, or other entities enrolled in Medicaid or contracted with a managed care plan to provide services to individuals eligible for Medicaid.
Medicare Advantage Plan - A Medicare-approved health plan offered by a private company that covers both hospital and medical services, often includes prescription drug coverage, and may offer extra coverage such as vision, hearing, dental and/or wellness programs. Each plan can charge different out-of-pocket costs and have different rules for how to get services. Such plans can be organized as health maintenance organizations, preferred provider organizations, coordinated care plans, and special needs plans.
Patient Responsibility - The cost of Medicaid long-term care services paid by the recipient, or the amount for which the recipient is responsible. This is determined by the Department of Children and Families and is based on the recipient’s income and where he/she lives.
Provider Service Networks (PSNs) - Health care delivery systems, owned and operated by hospitals, physician groups, or other providers. PSNs have a network of providers and facilities, which provide health care to enrollees.
Specialized Services - A service or specialized care to include, but not be limited to, personal assistance with bathing, dressing, ambulation, eating, supervision of or assistance with self-administered medications, assistance with securing health care from appropriate sources and transportation to such health care sources and socialization activities.
Temporary Loss Period - The period when an enrollee loses eligibility and regains it (no longer than 60 days). During this time, the recipient is able to continue to receive Long-term Care services through their LTC managed care plan.
Third Party - An individual, entity, or program, excluding Medicaid, that is, may be, could be, should be, or has been liable for all or part of the cost of medical services related to any medical assistance covered by Medicaid. A third party includes a third-party administrator or a pharmacy benefits manager.