ASKING FOR HELP

STEP 1: Contact the Managed Care Plan’s Care Manager/Case Coordinator

The primary job of your care manager is to work with you on getting the care you need. This means that you should inform the care manager when your situation changes (hospitalizations, new diagnoses, problems with providers, voluntary caregivers unable to help, etc.) If you need more services, ask. If there is no response from your care manager, ask in writing or contact the care manager’s supervisor. You can also ask the plan to send you a new case manager. If the situation isn’t resolved, see below.

STEP 2: Send a Formal Grievance to the Managed Care Plan

Every plan has a department to handle grievances and appeals. You can find where to send these in the plan’s Member Handbook, or call the plan’s service number and ask.

Appeals are only for challenging a plan’s decision to deny, reduce or terminate services or failure to provide services in a timely manner (also called an adverse benefit determination.)

Grievances are for everything else that you are dissatisfied about, including quality of care by service providers, problems communicating with providers or the plan (including case managers). Grievances can be filed at any time, either orally or in writing. The plan has to send you an acknowledgement that the grievance was received and you have the right to submit evidence in support of the grievance.

The plan can take up to 90 days to resolve the grievance. This is daunting, but it is still not a bad idea to file a grievance because it shows that you are trying to work with the plan to fix the problem. In the meantime, you can also file an AHCA Complaint.

STEP 3: File an AHCA Medicaid Complaint

AHCA oversees the LTC Waiver and has set up a way to file complaints online and by phone. You or the person filing on your behalf will need to have your Medicaid number handy. If filed online, there are places where supporting documents can be uploaded and where a narrative can by typed in (so don’t stress out if the multiple choice options don’t seem to fit.) You will be asked if you’ve contacted the plan about the problem, which is why Steps 1 and 2 are helpful.

If the situation is urgent, say so and say why. Also, a really urgent situation may justify filing an AHCA Complaint right away.

When you file an AHCA Complaint, a complaint counselor from AHCA may get back to you within a couple of days. If someone filed the complaint on your behalf, AHCA will not typically contact them unless they are your legal guardian or AHCA has a HIPAA release for that person. AHCA complaint counselors also contact the plan directly and may ask someone from the plan to call you.

STEP 4: Contact the State Legislator for your District

If you are having serious problems getting appropriate care and treatment despite your best efforts, it is not unreasonable to contact the state legislators in your district, regardless of party affiliation. Legislators are usually interested in hearing from constituents and can often help cut through red tape. Most have little real experience with the Medicaid HCBS programs, so it is important for them to understand how these programs are, and are not working.

STEP 5: Find an Advocate

If you cannot afford an attorney, there are advocacy organizations and legal aids that might be able to help, including:

Disability Rights Florida

The Legal Aid Organization in your area

Florida Health Justice Project

Florida Senior Legal Helpline (Age 60 and up): (888) 895-7873