Medicaid and the Medically Fragile Child

by Linda Brown, BrightStart Pediatrics

 

Florida Medicaid. It is a wonderful benefit for those in need, but it can also be very confusing. Several years ago, the state of Florida implemented a Statewide Medicaid Managed Care (SMMC) Program. This program requires most recipients to be enrolled in a Managed Medical Assistance (MMA) plan contracted with the State of Florida to administer their Medicaid benefits. This style of healthcare works well with the typical family, keeping the Primary Care Physician in the role of directing the care and offering a variety of services and providers. However, not every family is a typical family. If your family includes a child with special needs, that child may not fit well into the managed care approach. Children with more complex medical issues may see their specialists more often than their pediatrician. They require specialized medical equipment and therapies on a more consistent basis. Most importantly, their needs must be addressed in a timely manner as their development and future potential can be negatively affected by delays in service delivery.

For this reason, many of us in the state of Florida that work with medically fragile children lobbied for an option for these special children. As a result, specific groups of children with special needs were deemed “voluntary”. This means that they are not required to enroll in the MMA program. They can choose to enroll in an MMA plan, or they can choose to receive their medical services through traditional “Fee for Service” (FFS) Florida Medicaid. For this reason, many of us in the state of Florida that work with medically fragile children lobbied for an option for these special children. As a result, specific groups of children with special needs were deemed “voluntary”. This means that they are not required to enroll in the MMA program. They can choose to enroll in an MMA plan, or they can choose to receive their medical services through traditional “Fee for Service” (FFS) Florida Medicaid.

Examples of “qualified child” is any child who is a Medicaid recipient and is:

  • Enrolled in a PPEC (Prescribed Pediatric Extended Care) center. PPEC centers are day treatment programs that care for medically fragile infants and children, for up to 12 hours per day. They provide nursing and therapy (OT, PT, ST), in a child friendly center directed by the child’s own pediatrician and specialty physicians.
  • Enrolled in, or on the waiting list for, the Home & Community Based Service Waiver
  • A resident in a group home facility licensed under Chapter 393 (A full list of individuals with “voluntary” participation in MMA can be found in FS 409.972)

There is not a “right” or “wrong” answer to which plan, an MMA or FFS, is best for your medically fragile child. That is a decision made by you based on your child’s individual needs. If you are the caregiver for a child that qualifies for this voluntary status, it is important for you to know that you have a choice! If your qualified child is currently enrolled in an MMA and you feel that there are delays in service authorizations, you may want to consider choosing FFS. Talk with your child’s current providers to ensure that they accept FFS Medicaid. If they do, and you would like to make that change, speak with your PPEC Director or your Developmental Disabilities Waiver case manager to assist you in the process. Most importantly, be informed on the options available to your child as their needs may change as they grow!

Linda Brown is the president and owner of BrightStart Pediatrics, a PPEC program. BrightStart serves Central Florida from locations in Winter Garden, Sanford and Orlando. For more information visit online at brightstartpeds.com.

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