Waiver services may only be provided in a manner that is consistent with the service definitions, coverages and limitations established in the DS/HCBS Waiver Handbook (59G-8.200, Florida Administrative Code).

In addition, the Agency for Health Care Administration has established a set of conditions for determining the need for and appropriateness of Medicaid funded services for an enrolled beneficiary. The Waiver Handbook states that waiver services must be medically necessary as defined by Chapter 59G-1.010(166), Florida Administrative Code, as follows:

(a) ”Medically necessary” or “medical necessity” means that 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;
  
• 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 defined by the Medicaid program and not be experimental or investigational;
  
• Be reflective of the level of service that can safely be furnished; 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 beneficiary, the beneficiary’s caretaker, or the provider.

(b) 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, or a medical necessity, or a covered service.