Eligibility

Enrollment in Humana Healthy Horizons in Florida’s LTC plan is based on standards of eligibility established by the Department of Elder Affairs (DOEA) and Comprehensive Assessment and Review for Long- term Care Services (CARES). Financial eligibility is based on standards of eligibility established by the Florida Department of Children and Families (DCF).

Recipients eligible for enrollment must:

• Be 18 or older
• Reside in Florida
• Be at risk of nursing home placement, as determined by CARES
• Be financially eligible for enrollment, as determined by DCF
  • Financial eligibility requirements for the program are the same as the Medicaid Institutional Care program (ICP).

For specific information regarding eligibility criteria, please contact your provider contracting representative or care management in your region.

Referrals

If an individual believes they may qualify for the program, the individual or the individual’s representative must contact the local Aging and Disability Resource Center (ADRC) office to apply for the Humana Healthy Horizons plan. As a provider, if you decide to assist the individual with the application process, you must obtain the individual’s consent via the  Authorized Representative Form . The individual or the provider is welcome to contact Humana Healthy Horizons for program information.

Locate an ADRC office in your area .

Covered services

Long-term care coverage is limited to those services authorized in writing by the member’s care manager and in accordance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbooks. Covered services include:

Adult day care

Adult day care provides members with supervision, socialization and therapeutic activities in an outpatient setting while offering respite for caregivers. Meals are included as part of this service when the member is at the center during mealtimes. Adult day care health services include, but are not limited to, the following:

• Supervised, recreational activities at least 80% of the day
• Physical exercises
• Cognitive exercises
• Lunch and snacks
•  Coordination of transportation
• Medication administration and management
• Vital signs monitoring
•  Basic health monitoring, including glucose level checks
• Referral to physical therapy screening (conducted on-site)
• Hands-on assistance with personal care, such as toileting, eating, ambulating and grooming

Assistive care

Assistive care offers 24-hour services for members in assisted living facilities, adult family care homes and residential treatment facilities. Services include:

• 24-hour access to staff
• Assistance with ambulation
• Assistance with transferring
• Assistance with eating
• Dementia care
• Dressing and grooming
• Emergency/disaster plan
• Escort services
• Housekeeping
• Incontinence management
• Medication management
• Personal laundry and linen services
• 3 meals per day, plus snacks
• Transportation
• Utilities
• Wander guard

Assisted living facility 

Assisted living facilities (ALFs) provide members with an alternative living arrangement that offers members access to 24-hour staff in a home-like environment. Meals, personal care and housekeeping services are provided by the staff. ALFs also may be used for respite care. ALFs provide members with the following services or as indicated in each individual provider contract:

• 24-hour access to staff
• Bathing assistance
• Medication management
• 3 meals per day, plus snacks
• Incontinence management
• Incontinence supplies
• Nutritional supplements
• Housekeeping
• Personal laundry and linen service
• Utilities
• Transportation or coordination of transportation
• Alarmed doors or locked unit
• Personal hygiene items
• Escort to dining room
• Emergency/disaster plan
• Dementia care 

Transportation

All Humana Healthy Horizons Comprehensive Plan contracts with ALFs require the ALF to coordinate transportation for members. Humana Healthy Horizons members are eligible for transportation trips to long-term-care-covered services as authorized by Humana Healthy Horizons. Please contact the member’s care manager for authorization approval. Humana Healthy Horizons members should use their health plan ID card for all covered transportation services (including emergency transportation).

Behavioral management

Behavioral management offers behavioral healthcare services to help address mental health or substance use needs of long-term care members. These services are used to maximize reduction of the member’s disability and restoration of the member’s best functional level.

Home accessibility adaption services

Home accessibility adaption services help members make modifications to their home that promote safety and reduce barriers for the member’s treatment plan. Installation of grab bars and ramps, widening doors, modifying bathroom facilities or installing specialized electric and plumbing systems accommodate medical equipment and supplies necessary for the welfare of the member. These services exclude home modifications that may be considered home improvements. All services must be provided in accordance with applicable state and local building codes.

Members or caregivers are contacted within 2 business days of receipt of authorization from the Humana Healthy Horizons care manager to schedule an appointment.

Home-delivered meals

Home-delivered meal services ensure members who are unable to shop or cook receive nutritionally sound meals. Meals are delivered to the home hot, cold, frozen, dried or canned, with a satisfactory storage life. Each meal is designed to provide a third of the recommended dietary allowance. A signature must be obtained from the member or caregiver at the time of meal delivery. Members coordinate changes to their meal delivery through their care manager.

Home healthcare

Providers contracted with Humana Healthy Horizons must adhere to the following procedures when providing services:

• Humana Healthy Horizons reserves the right to make decisions regarding the plan of care for its members and request specific services and frequency to meet the member’s needs. Services may be provided in a member’s home or an ALF on an hourly or per-visit fee, as authorized by Humana Healthy Horizons. The home healthcare (HHC) provider has a maximum of 2 hours to inform Humana Healthy Horizons staff if the requested services can be provided and the anticipated start date.
• HHC staff are required to complete AHCA’s designated form, verifying that the services were provided at the time of each visit, complete with the member’s signature. The completed form also must include the date and time of service, the member’s signature, and the names of direct care staff who provided the service.
• In compliance with the 21st Century CURES Act, providers are required to utilize electronic visit verification (EVV) to electronically monitor, track and confirm services provided in the home setting.
• If a Humana Healthy Horizons member is entitled to Medicare home health benefits, these benefits are utilized before Humana Healthy Horizons authorizes home health benefits, as described in your contract with Humana Healthy Horizons.
• Missed visits must be documented via EVV and reported within 3 hours of the original appointment time.

Home health services are authorized by the care manager on a weekly basis (Sunday through Saturday). Preauthorization is required by the care manager to deliver services that exceed the number of hours authorized in a day or in a week. The only variation allowed without preauthorization is when switching the day(s) of services within the same week with member consent. If the schedule change is permanent, the provider should inform the care manager of the change. 

Adult companion

Companions can perform tasks, such as meal preparation, laundry and shopping, while providing socialization for the member. This includes light housekeeping tasks incidental to the care and supervision of the member. Services do not include hands-on nursing care or bathing assistance.

Family training 

Family training offers family members advice, demonstrations and tips to promote safety while caring for the member. Topics include diabetes management, how to transfer an individual and how to use safety equipment properly.

Homemaker services

Homemaker services support members with general household activities, including meal preparation, laundry and light housekeeping.

Occupational therapy

Occupational therapy works to restore, improve or maintain impaired function for daily living tasks (e.g., using a fork, using a shower chair or cooking from a wheelchair).

Personal care

Personal care service helps members bathe, dress, eat, maintain personal hygiene and assists in other activities of daily living. A personal care worker is permitted to help with incidental housekeeping, such as making beds and cleaning up areas where they performed services.

Physical therapy

Physical therapy works to restore, improve or maintain impaired function in regard to ambulation and mobility, including walking, transferring to or using a walker or wheelchair.

Respite care

Respite care services help caregivers get relief from their caretaking duties for short periods of time. Respite care may be provided by a home health agency, assisted living community or a skilled nursing facility. Respite care is not a substitute for care usually provided by a registered nurse, a licensed practical nurse or a therapist.

Hospice

Hospice delivers forms of palliative medical care and other services designed to meet the physical, social, psychological, emotional and spiritual needs of terminally ill members and their families. Care managers coordinate this care with members enrolled in Medicare hospice services. If a member requires any hospice service traditionally covered by Medicaid, preauthorization may be required from the care manager.

Members can be simultaneously enrolled in Humana Healthy Horizons and hospice. Medicaid hospice services require prior approval from Humana Healthy Horizons. Dual-eligible members may enroll in Medicare hospice; in these instances, the care manager coordinates services. Members or their representatives are required to contact the Humana Healthy Horizons care manager before enrolling in a hospice program.

Medical supplies

Consumable

Consumable medical supplies include adult disposable diapers, tubes of ointment, cotton balls and alcohol for use of injections, medicated bandages, gauze and tape, colostomy, catheter and other consumable supplies not covered by Medicare. Supplies covered under home health service, or personal toiletries and household items, including detergents, bleach, paper towels or prescription drugs, are not covered. This service does not include personal toiletries, over-the-counter medications or household items.

The consumable medical supply service requires written authorization from the Humana Healthy Horizons care manager. Supplies are delivered to the member’s home and the member or caregiver must sign an itemized receipt. Members must go through their care manager to make changes to an order. Nutritional supplements require both a provider’s prescription and preauthorization from the Humana Healthy Horizons care manager. Members authorized to live in a contracted facility receive this service directly from the facility.

Durable medical equipment 

Durable medical equipment (DME) is medical equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury and is appropriate for use in the recipient’s home. Medicare and Medicaid acute-care programs cover most DME that Humana Healthy Horizons members need. Items needed by Humana Healthy Horizons members not covered by Medicare require preauthorization from the Humana Healthy Horizons care manager.

Skilled nursing facility services

Skilled nursing facility (SNF) services are coordinated with members’ acute-care coverage. If members are dually eligible for Medicare and Medicaid, Humana Healthy Horizons is responsible for coinsurance as per Medicaid crossover guidelines.

Claims must be submitted with the Medicare Explanation of Benefits (EOB).

SNF staff are expected to inform Humana Healthy Horizons staff of changes or concerns identified while providing services to members to ensure that members’ needs are met.

Respite care

Respite care offers caregivers relief from caregiving responsibilities for short periods of time. Respite care may be provided by a SNF. Respite care is not a substitute for the care usually provided by a registered nurse, a licensed practical nurse or a therapist.

Transportation

All Humana Healthy Horizons contracts with SNFs require the SNF to coordinate transportation for our members. Humana Healthy Horizons members are eligible for transportation to long-term-care-covered services, as authorized by Humana. Please contact the member’s care manager for authorization approval. Our members use their health plan ID card for all covered transportation services (including emergency transportation).

Change in member needs

Providers must inform Humana Healthy Horizons staff of changes or concerns they identify while providing services to members to ensure that members’ needs are met. This includes notification of members’ admission to a hospital and/or entering a Medicare or Medicaid hospice program. Medicaid hospice services require preauthorization from Humana Healthy Horizons. Notification must be made within 24 hours of a significant change in members’ healthcare needs.

Custodial care

All members who require custodial care must be assessed and Humana Healthy Horizons must determine that the member can no longer live in a less restrictive setting. Members who receive approval for placement in a contracted SNF for custodial care are required to pay the facility a patient responsibility amount based on their income, determined by the Department of Children and Families. Prior authorization is required by Humana.

Nutrition assessment/ risk reduction

Nutrition assessment and risk reduction services offers members an assessment, hands-on care and guidance for the caregiver and members to address the members’ nutritional needs. Nutritional assessments are made by dietitians, usually from a home health agency. Humana Healthy Horizons reserves the right to determine the plan of care for its members and send a request for specific services and at a frequency to meet members’ needs. Services may be provided in members’ homes or assisted living facilities on a 15-minute increment fee as authorized by Humana.

Personal emergency response system

Personal emergency response system (PERS) services installs and maintains an electronic device that enables members at high risk of institutionalization to secure help in an emergency.

A PERS is connected to the member’s phone and programmed to signal a response center once a “help” button is activated. The member also may wear a portable “help” button to allow for mobility. PERS services generally are limited to those members who live alone or are alone for a significant part of the day and who otherwise would require extensive supervision. Providers train Humana Healthy Horizons members on the use and monthly testing of the unit after installation and notify Humana via telephone or fax if a member utilizes the system.

Providers are expected to install a medical alert system within 5 business days after receiving written authorization from a Humana Healthy Horizons care manager.

Pharmacy benefits

Humana Healthy Horizons offers an over-the-counter (OTC) medication benefit to our members via our mail-order service, PrescribeIT® Rx. Members can find the  OTC order form  online. Refer to the member handbook for additional information.

Quality enhancements

Quality enhancements are education and/or community-based services coordinated by the care manager to address concerns related to safety measures in the home, fall prevention, disease management, education on end-of-life issues, advance directives and domestic violence.

Transportation

Humana Healthy Horizons members are eligible for transportation to long-term-care-covered services, as authorized by Humana. Please contact the plan for authorization approval. Our members use their health plan ID card for all covered transportation services (including emergency transportation).

Transportation for nonmedical appointments can be provided for services but require preauthorization. Please contact the member’s assigned care managers for more details.

Expanded benefits

Expanded services are those services or benefits offered by Humana Healthy Horizons and approved in writing by AHCA that are not otherwise covered or that exceed limits outlined in the Medicaid State Plan, Florida Medicaid Coverage and Limitations Handbooks and the Florida Medicaid Fee Schedules. These services are in excess of the amount, duration and scope of those services listed above. In instances when an expanded benefit is also a Medicaid covered service, Humana Healthy Horizons administers the benefit in accordance with all applicable service standards pursuant to its contract, the Florida Medicaid State Plan and any Medicaid Coverage and Limitations Handbooks. Humana Healthy Horizons members have specific enhanced benefits. Please see the member handbook for benefit descriptions and details.

Long-term care expanded benefits

If a member needs services, a care manager will issue an authorization for covered services to a participating provider. Our care managers will assess members’ needs prior to ordering services.

Procedures for authorization of services

• Upon determination that a member needs services from a facility or company, the care management team will contact the provider to inquire if the services can be provided and provide an authorization. The authorization is valid for the period of time specified or otherwise indicated on the authorization. If dates of services are not established, the provider’s staff is responsible for following up with the plan with the date that services will begin.
• If a member needs to stop services for a short period of time (e.g., due to a hospitalization), the care management team will fax an updated authorization to the provider.
• If a member no longer needs services from the provider, the care management team will fax a termination of services authorization to the provider.
• If a member needs an increase or decrease in services, the care management team will fax an updated authorization to the provider.

If you have questions or concerns about a member, please contact our local care management team. If authorized services are unable to be rendered at the date and time agreed upon for the member, please contact the Care Coach immediately to report the missed service.  Missed Services must be reported immediately so that alternate services can be coordinated for the member and ensure the member’s contingency plan is followed.

Out-of-network/noncontracted services

An out-of-network provider is a provider who is not directly contracted with the Humana Long-term Care Plan. The Humana Comprehensive Plan is not responsible for payment of services provided by an out-of-network provider without written prior authorization.

Non-contracted services are services not defined on Schedule B of your contract. Humana is not responsible for payment of non-contracted services. If you or your staff identifies a service that a member may require that is not listed in your contract, please contact the member’s care manager to evaluate the member’s needs and determine if the service can be authorized by Humana. If the care manager determines that the service should be authorized by Humana, the care manager will contact your local provider contracting representative to discuss adding an addendum to your contract.

Humana Comprehensive Plan is not responsible for payments of services ordered by a member from a participating provider, without written preauthorization from a Humana Comprehensive Plan care manager. Please contact the member’s assigned care manager to request authorization prior to providing services.

Medical Necessity

Medically necessary care or medical necessity is determined, as per 59G-1.010(166), Florida Administrative Code (FAC), as follows. “Medically necessary” or “medical necessity” means that the medical or allied care, goods or services furnished or ordered must meet the following conditions: 

• Be necessary to protect life, to prevent significant illness or significant disability or to alleviate severe pain; o This requirement only applies to recipients age 21 years or older.
• Be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;
• Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
• Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and
• Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker or the provider. 

“Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.

The fact that a provider has prescribed, recommended or approved medical or allied care, goods or services does not, in itself, make such care, goods or services medically necessary, a medical necessity or a covered service.

Humana maintains and complies with HIPAA standards for the submission and adjudication of claims. This section will provide information regarding the submission and payment process. If you have questions or would like training regarding submitting claims, please contact your local provider contracting representative.

Claim submission

A clean claim is a claim that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity, pursuant to 42 CFR 447.45.

All claims should be submitted to the Humana Long-term Care Plan within six months from the date of service, discharge from an inpatient setting or the date that the provider was furnished with the correct name and address of the managed care plan. When the managed care plan is the secondary payer and the primary payer is an entity other than Medicare, the managed care plan shall require the provider to submit the claim to the managed care plan within 90 days after the final determination of the primary payer, in accordance with the Medicaid Provider General Handbook. When the managed care plan is the secondary payer and the primary payer is Medicare, the managed care plan shall require the provider to submit the claim to the managed care plan in accordance with timelines established in the Medicaid Provider General Handbook. The managed care plan shall not deny Medicare crossover claims solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds three years. Humana Long-term Care Plan shall not deny claims submitted by a nonparticipating provider solely based on the period between the date of service and the date of clean claim submission, unless that period exceeds 365 days. Claims that are incomplete, illegible or missing identifiable information may delay payment or could result in a denial of payment. For more information on claim submission, please visit our website at Humana.com.

Electronic claims

Humana Healthy Horizons in Florida Comprehensive Plan can receive electronic claims submission. The acceptable formats include X12 5010 837 institutional, professional and dental formats. Humana Healthy Horizons in Florida Comprehensive Plan also allows for direct data entry (DDE) through Availity.com.

When filing an electronic claim, you will need to utilize the following payer ID: 61115 for long-term care claims.

For questions on how to enroll in electronic claims submissions, please contact:

• Email: FLResolutionLTSS@humana.com
• Phone: 888-998-7735
• Web: Availity.com

Paper claims

Paper claims should be submitted to the address listed on the back of the member’s ID card or to the address listed below:

Humana Healthy Horizons in Florida Long-term Care Plan
Attn: Claims Department
P.O. Box 14732
Lexington, KY 40512-4732
Learn more about claims and payments