393.065 Application and eligibility determination.—
(1)(a) The agency shall develop and implement an online application process that, at a minimum, supports paperless, electronic application submissions with immediate e-mail confirmation to each applicant to acknowledge receipt of application upon submission. The online application system must allow an applicant to review the status of a submitted application and respond to provide additional information. The online application must allow an applicant to apply for crisis enrollment.
(b) The agency shall maintain access to a printable paper application on its website and, upon request, must provide an applicant with a printed paper application. Paper applications may be submitted in writing to the agency in the region in which the applicant resides, sent to a central or regional address through regular United States mail, or faxed to a central or regional confidential fax number. The agency shall acknowledge receipt of all applications it receives, regardless of the manner of submission, with an immediate receipt confirmation provided in the same manner in which the application was received, unless the applicant has designated an alternative preferred method of communication on the submitted application.
(c) The agency must review each submitted application in accordance with federal time standards.
1. If the agency determines additional documentation is necessary to make an eligibility determination, the agency may request the additional documentation from the applicant.
2. When necessary to definitively identify individual conditions or needs, the agency or its designee must provide a comprehensive assessment.
(d)1. For purposes of this paragraph, the term “complete application” means an application submitted to the agency which is signed and dated by the applicant or an individual with legal authority to apply for public benefits on behalf of the applicant, is responsive on all parts of the application, and contains documentation of a diagnosis.
2. If the applicant requesting enrollment in the home and community-based services Medicaid waiver program for individuals with developmental disabilities is deemed to be in crisis as described in paragraph (5)(a), the agency must make an eligibility determination within 15 calendar days after receipt of a complete application.
3. If the applicant meets the criteria specified in paragraph (5)(b), the agency must review and make an eligibility determination as soon as practicable after receipt of a complete application.
4. If the application meets any of the criteria specified in paragraphs (5)(c)-(g), the agency must make an eligibility determination within 60 days after receipt of a complete application.
(e) Any delays in the eligibility determination process, or any tolling of the time standard until certain information or actions have been completed, must be conveyed to the client as soon as such delays are known through verbal contact with the client or the client’s designated caregiver and confirmed by a written notice of the delay, the anticipated length of delay, and a contact person for the client.
(2) In order to be eligible for services under this chapter, the agency must determine that the applicant has met all eligibility requirements in rule, including having a developmental disability and being domiciled in this state. Information accumulated by other agencies, including professional reports and collateral data, shall be considered in this process when available.
(3) The agency or its designee shall notify each applicant, in writing, of its eligibility determination. Any applicant or client determined by the agency to be ineligible for services has the right to appeal this determination pursuant to ss. 120.569 and 120.57.
(4) Before admission to an intermediate care facility for individuals with intellectual disabilities and to ensure that the setting is the least restrictive to meet the individual’s needs, the agency must authorize admission pursuant to this subsection. As part of the authorization, the agency or its designee must conduct a comprehensive assessment that includes medical necessity, level of care, and level of reimbursement.
(5) Except as provided in subsections (6) and (7), if a client seeking enrollment in the developmental disabilities home and community-based services Medicaid waiver program meets the level of care requirement for an intermediate care facility for individuals with intellectual disabilities pursuant to 42 C.F.R. ss. 435.217(b)(1) and 440.150, the agency must assign the client to an appropriate preenrollment category pursuant to this subsection and must provide priority to clients waiting for waiver services in the following order:
(a) Category 1, which includes clients deemed to be in crisis as described in rule, must be given first priority in moving from the preenrollment categories to the waiver.
(b) Category 2, which includes clients in the preenrollment categories who are:
1. From the child welfare system with an open case in the Department of Children and Families’ statewide automated child welfare information system and who are either:
a. Transitioning out of the child welfare system into permanency; or
b. At least 18 years but not yet 22 years of age and who need both waiver services and extended foster care services; or
2. At least 18 years but not yet 22 years of age and who withdrew consent pursuant to s. 39.6251(5)(c) to remain in the extended foster care system.
For individuals who are at least 18 years but not yet 22 years of age and who are eligible under sub-subparagraph 1.b., the agency must provide waiver services, including residential habilitation, and must actively participate in transition planning activities, including, but not limited to, individualized service coordination, case management support, and ensuring continuity of care pursuant to s. 39.6035. The community-based care lead agency must fund room and board at the rate established in s. 409.145(3) and provide case management and related services as defined in s. 409.986(3)(e). Individuals may receive both waiver services and services under s. 39.6251. Services may not duplicate services available through the Medicaid state plan.
(c) Category 3, which includes, but is not required to be limited to, clients:
1. Whose caregiver has a documented condition that is expected to render the caregiver unable to provide care within the next 12 months and for whom a caregiver is required but no alternate caregiver is available;
2. At substantial risk of incarceration or court commitment without supports;
3. Whose documented behaviors or physical needs place them or their caregiver at risk of serious harm and other supports are not currently available to alleviate the situation; or
4. Who are identified as ready for discharge within the next year from a state mental health hospital or skilled nursing facility and who require a caregiver but for whom no caregiver is available or whose caregiver is unable to provide the care needed.
(d) Category 4, which includes, but is not required to be limited to, clients whose caregivers are 60 years of age or older and for whom a caregiver is required but no alternate caregiver is available.
(e) Category 5, which includes, but is not required to be limited to, clients who are expected to graduate within the next 12 months from secondary school and need support to obtain a meaningful day activity, maintain competitive employment, or pursue an accredited program of postsecondary education to which they have been accepted.
(f) Category 6, which includes clients 21 years of age or older who do not meet the criteria for category 1, category 2, category 3, category 4, or category 5.
(g) Category 7, which includes clients younger than 21 years of age who do not meet the criteria for category 1, category 2, category 3, or category 4.
Within preenrollment categories 3, 4, 5, 6, and 7, the agency shall prioritize clients in the order of the date that the client is determined eligible for waiver services.
(6) The agency must allow an individual who meets the eligibility requirements of subsection (2) to receive home and community-based services in this state if the individual’s parent or legal guardian is an active-duty military servicemember and if, at the time of the servicemember’s transfer to this state, the individual was receiving home and community-based services in another state.
(7) The agency must allow an individual with a diagnosis of Phelan-McDermid syndrome who meets the eligibility requirements of subsection (2) to receive home and community-based services.
(8) Only a client may be eligible for services under the developmental disabilities home and community-based services Medicaid waiver program. For a client to receive services under the developmental disabilities home and community-based services Medicaid waiver program, there must be available funding pursuant to s. 393.0662 or through a legislative appropriation and the client must meet all of the following:
(a) The eligibility requirements of subsection (2), which must be confirmed by the agency.
(b) The eligibility requirements for the Florida Medicaid program under Title XIX of the Social Security Act, as amended, or the Supplemental Security Income program.
(c) The level of care requirements for an intermediate care facility for individuals with developmental disabilities pursuant to 42 C.F.R. ss. 435.217(b)(1) and 440.150.
(d) The requirements provided in the approved federal waiver authorized pursuant to s. 1915(c) of the Social Security Act and 42 C.F.R. s. 441.302.
(9) Agency action that selects individuals to receive waiver services pursuant to this section does not establish a right to a hearing or an administrative proceeding under chapter 120 for individuals remaining in the preenrollment categories.
(10) The client, the client’s guardian, or the client’s family must ensure that accurate, up-to-date contact information is provided to the agency at all times. Notwithstanding s. 393.0651, the agency must send an annual letter requesting updated information from the client, the client’s guardian, or the client’s family.
(11)(a) The agency must provide the following information to all applicants or their parents, legal guardians, or family members:
1. A brief overview of the vocational rehabilitation services offered through the Division of Vocational Rehabilitation of the Department of Education, including a hyperlink or website address that provides access to the application for such services;
2. A brief overview of the Florida ABLE program as established under s. 1009.986, including a hyperlink or website address that provides access to the application for establishing an ABLE account as defined in s. 1009.986(2);
3. A brief overview of the supplemental security income benefits and social security disability income benefits available under Title XVI of the Social Security Act, as amended, including a hyperlink or website address that provides access to the application for such benefits;
4. A statement indicating that the applicant’s local public school district may provide specialized instructional services, including transition programs, for students with special education needs;
5. A brief overview of programs and services funded through the Florida Center for Students with Unique Abilities, including contact information for each state-approved Florida Postsecondary Comprehensive Transition Program;
6. A brief overview of decisionmaking options for individuals with disabilities, guardianship under chapter 744, and alternatives to guardianship as defined in s. 744.334(1), which may include contact information for organizations that the agency believes would be helpful in assisting with such decisions;
7. A brief overview of the referral tools made available through the agency, including a hyperlink or website address that provides access to such tools; and
8. A statement indicating that some waiver providers may serve private-pay individuals.
(b) The agency must provide the information required in paragraph (a) in writing to an applicant or his or her parent, legal guardian, or family member along with a written disclosure statement in substantially the following form:
DISCLOSURE STATEMENT
Each program and service has its own eligibility requirements. By providing the information specified in section 393.065(11)(a), Florida Statutes, the agency does not guarantee an applicant’s eligibility for or enrollment in any program or service.
(c) The agency must also publish the information required in paragraph (a) and the disclosure statement in paragraph (b) on its website, and must provide that information and statement annually to each client placed in the preenrollment categories or to the parent, legal guardian, or family member of such client.
(12) To ensure transparency and timely access to information, the agency shall post on its website in a conspicuous location the total number of individuals in each priority category by county of residence. The posted numbers shall reflect the current status of the preenrollment priority list and shall be updated at least every 5 days.
(13) The agency and the Agency for Health Care Administration may adopt rules specifying application procedures, criteria associated with the preenrollment categories, procedures for administering the preenrollment, including tools for prioritizing waiver enrollment within preenrollment categories, and eligibility requirements as needed to administer this section.
...Wilson,
361 S.E.2d 734, 739 (N.C. 1987).6 In cases that involve presumptive Medicare
5. For example, the Agency for Persons with Disabilities maintains an
extensive waiting list for services available to individuals with particular
disabilities. See § 393.065, Fla....
...appeals a "Final Order Denying Petition for Administrative Hearing" in which the Agency for Persons with Disabilities (APD) ruled that J.M. was not entitled to a hearing under section 120.57(1), Florida Statutes (2005), to resolve a dispute arising under section 393.0651, Florida Statutes (2005), stating: The Office of Appeal Hearings, administratively located [not within the Agency for Persons With Disabilities but] within the Department of Children and Families, was created to provide administrativ...
...93, including the . . . programmatic management of Medicaid waivers established to provide services to persons with developmental disabilities."). In particular, APD is responsible for creating an individual support plan for each of its clients, see 393.0651, Fla. Stat. (2005), and for annual review of these plans. See 393.0651(7), Fla. Stat. (2005). These obligations encompass responsibility and authority for making determinations of eligibility for clients to receive developmental disability services. See 393.065(1), Fla....
...individual support plan, or the annual review thereof, shall have the right to file a notice to challenge the decision pursuant to ss. 120.569 and 120.57. Notice of such right to appeal shall be included in all support plans provided by the agency. 393.0651(8), Fla....
...(2005) (emphasis added). With respect to initial eligibility determinations at least, the statute also provides: "Any applicant determined by the agency to be ineligible for developmental services has the right to appeal this decision pursuant to ss. 120.569 and 120.57." 393.065(3), Fla....
...We therefore leave for another day mapping the exemption's exact contours. The specific statutes in chapter 393 necessarily control over any general exemption in section 120.80(7), even assuming the exemption provided in 120.80(7) could be read to apply to APD. See 393.065-.0651, Fla....
...2d at 46, also supports this result. The first time chapter 393 incorporated a provision entitling an applicant for developmental disability services to a hearing pursuant to section 120.57, was in 1988, see Ch. 88-398, 7, at 2337, Laws of Fla. (creating section 393.065(3), Florida Statutes (1988)), while the section 120.80(7) exemption can be traced back to the Administrative Procedure Act of 1974. See Ch. 74-310, 1, at 961, Laws of Fla. [6] Section 393.0651, Florida Statutes, was originally enacted in 1989, and includes the right to a hearing pursuant to section 120.57....
...l. Section 120.80(7) has no application here. III. APD must grant a formal hearing pursuant to section 120.57(1) when material facts are in dispute and an applicant or client is "determined by the agency to be ineligible for developmental services," 393.065(3), Fla. Stat. (2005), if the applicant or client "is substantially affected by the . . . initial family or individual support plan, or the annual review thereof." 393.0651(8), Fla....
...I concur for the purpose of separately expressing my disagreement with what appears to be the policy position of the Agency for Persons with Disabilities (APD), which denies developmentally disabled persons the right to a section 120.57 hearing, despite language in section 393.065(3), [7] placed within the Developmental Disabilities Prevention and Community Services Act, clearly providing them such relief. As explained in the majority's opinion, recourse to chapter 120 remedies was first conferred in 1988, through the enactment of section 393.065; however, the APD or its predecessors have continued to rely indiscriminately on the section 120.80(7) exemption since its creation in 1974. I think it reasonably clear that the more general provisions of section 120.80(7) cannot trump the later enacted and more specific provisions of sections 393.065(3) and 393.125, authorizing resort to section 120.57....
...Having said the above, it is not altogether clear to me whether the legislature intended that chapter 120 processes should be afforded to resolve a dispute such as that in the present case where the level of residential habilitation care is reduced, rather than denied altogether. Section 393.065(3), Florida Statutes (2005), explicitly states that an "applicant determined by the agency to be ineligible for developmental services has the right to appeal this decision pursuant to ss. 120.569 and 120.57." (Emphasis added.) In the case at bar J.M. availed himself of the procedure supplied in both sections 393.065 and 409.285, Florida Statutes (2005)....
...olely to fair hearings, its purpose has not been expressed with the clarity one should reasonably expect. As it now stands, an applicant denied developmental services has the option of seeking either a section 120.57 proceeding, accorded by sections 393.065 and 393.125, or a fair hearing as authorized by section 409.285....
...See Russell v. Agency for Persons With Disabilities, 929 So.2d 601 (Fla. 1st DCA 2006). The agency denied his application to be considered a danger to himself and others, which would qualify him to be placed at the top of the waiting list pursuant to section 393.065(5), Florida Statutes, and Florida Administrative Code Rule 65G-1.047....
...entered the order. We agree with DCF that the circuit court exceeded its authority under the guardianship statutes. See Ch. 744, Fla. Stat. (2005). The statutes requires one seeking developmental services to submit a written application to DCF. See § 393.065(1), Fla. Stat. (2005). DCF is required to notify the applicant of its eligibility determination. See § 393.065(3), Fla....
...There is no requirement that DCF notify a court or any counsel in guardianship proceedings of its determination. Nothing in the guardianship statutes authorizes the court to create its own procedure for assessment for developmental services, and there is no evidence that DCF has failed to comply with its obligations under section 393.065....
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