Understanding The Maze of Florida's Long Term Care Medicaid Programs
Isenhour Senior Services
May 22, 2024
Florida - Southwest
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As a Certified Senior Advisor
specializing in Medicaid representation in Florida, our staff goes breathless
attempting to explain the differences between the various long term care
Medicaid programs offered here in Florida.
In this article, I will attempt to cover as many aspects of these
programs as possible and assist you through this maze of confusion.
Long Term Care Programs:
1. ICP - Institutional Care Program (Nursing
Home Medicaid) – This program is the one
that most of the inquiries to our office are calling about. ICP is for nursing home residents who need assistance
in paying the high cost associated with this level of care. The private pay cost of this type of care can
range anywhere from $9,000 to over $15,000 per month. This program is for those who possess a need
of assistance with at least 3 activities of daily living (bathing, dressing,
toileting, transferring, feeding oneself) or are a hospice patient in addition
to residing in a skilled nursing facility.
2. Hospice - For individuals with a life
expectancy of 6 months or less. While Hospice services are primarily
covered by Medicare, if a person resides in a nursing facility and are applying
for Medicaid, hospice would assist in managing the care even in the nursing
facility.
3. HCBS - Home and Community Based Services
(Waiver programs)
A. Hope Pace - All-inclusive medical program
that assists people who are living independently. The individual is expected to use the medical
professionals that Hope Pace contracts with and recipient would attend their
health center at least one day per week to see doctors there. Transportation is provided in addition to
many other benefits. This program provides supportive services in order to
allow the applicant to maintain their independence and the goal is to avoid
placement for as long as possible. Hope
Pace is a pilot program and not available in all counties. For more information, their phone number is
239-985-6400.
B. Medicaid Waiver for care at home, daycare or in
an Assisted Living Facility-These programs are funded and have a waiting list
which is managed by a State agency called the Area Agency on Aging. Each person who calls to be added to the
waiting list is given a phone assessment appointment to be called by the agency
at a later date and asked a series of questions. The phone assessment takes
about 45 minutes and afterward the recipient is given a priority score based on
physical need for care and is placed on the list based on their priority score.
Those with the most need for assistance with activities of daily living are
given a higher priority score than others with less need for physical help. The
goal is to avoid nursing home placement, so those at a higher risk of possible
nursing home placement are moved to a higher position than those that are more
independent. They will usually ask
financial questions as well during the phone assessment. Phone number for Area
Agency on Aging is 239-652-6900.
Qualification and Procedure:
All long-term care Medicaid programs have the same income
and asset limitations. The applications
are submitted using an online portal through the Department of Children and Families
(DCF). You may also fax in a paper application to the department, but
submitting online gives access to information much more efficiently than
waiting for notifications to come via U.S. Mail. Since you would be using the
online portal, you may log in whenever you would like to check on your case and
the online portal allows changes to be reported more easily and notices may be
viewed upon generation. This application
process is comprehensive in terms of all financial aspects of the applicant’s
situation in order for the caseworker to determine eligibility.
The Medicaid
applicant income limit is currently $2,829 per month and increases each year commensurate
with Social Security cost of living adjustments. The individual’s gross income is what is counted
which is the amount prior to any deductions such as Medicare or other health
insurance premiums, tax withholding, union dues, life insurance premiums,
etc. If the applicant’s gross countable
income exceeds the limitation, they would need to obtain the assistance of an
elder law attorney to provide a remedy. Isenhour
Senior Services is not a law firm, but would be able to offer a list of
competent attorneys to contact for the purpose of legal needs as they arise.
Allowable assets may include Florida homestead
with a maximum value of $713,000 for a single individual and unlimited value if
a spouse or minor child is living in the home; other income producing real
estate that is producing fair market value income (net income after calculated
expenses is counted as income); additional property that is listed for sale at
fair market value; vehicle of any value; IRAs if there is an income distribution
in place; Irrevocable funeral arrangements of any value; An additional $2,500
in other burial funds which can be in the form of savings, life insurance cash
value, or other assets that the value can be verified; and up to $2,000 in
other liquid or non-liquid assets.
For nursing home Medicaid applicants, if there is a spouse
living in the community, the community spouse’s resource limit is $154,140 in
addition to the previously mentioned items.
For nursing home applicants, there is usually a dollar amount that is to
be paid from their income called a patient responsibility. The patient responsibility is paid to the nursing
home and Medicaid pays the remaining balance of the charges. The applicant is allowed to keep $160 for
personal needs and enough to cover any medical premiums such as dental or
health insurance, hearing aid leases, etc..
When there is a community spouse living at home or in a
private pay assisted living facility and their ill spouse is applying for nursing
home Medicaid, their information is also included in the applicant’s
application for benefits and the community spouse may possess the ability to
retain some of the applicant's income in order to meet their shelter expenses
in the community. Currently the State of
Florida allows the community spouse to retain a minimum of $2,465 from both
spouse's income sources in order to meet their needs in the community. If the spouse has excess shelter costs, such
as assisted living expenses, mortgage, rent or other high shelter expenses,
they are allowed to keep more of the applicant's income, with a maximum total
income allowance of $3,854 per month. This
amount includes both spouse’s gross monthly income. If the community spouse needs even more than
this amount to cover their expenses in the community, they may wish to seek
legal advice for a court order for spousal support.
For the Assisted Living Medicaid Waiver program, once the
applicant’s name has come up on the Area Agency on Aging’s waiting list and the
application is submitted and approved (usually a 60-day time period), then
benefits begin the following month. The Medicaid recipient would then need to
choose a managed care provider which would be the one that the facility they
are preferring accepts. That provider would
contribute up to somewhere between $1300 and $1600 per month toward the charges
after the recipient has contributed their income minus allowances. The rest of the ALF’s charges would still need
to be paid so that the facility still receives full payment. If the recipient’s income is not sufficient
to cover the remaining charges and the family cannot cover the shortfall, the recipient
may need to enter a nursing home if they qualify physically for that level of
care, since nursing home Medicaid only expects the applicant to pay in less than
their monthly income as their patient responsibility. This same Medicaid Waiver program can assist
with homecare hours and other services which would help them to remain in their
home if that is a safe decision.
For all long-term care programs other than Hospice, there is
a physical level of care evaluation that is completed by the Department of
Elder Affairs which would determine if the individual meets the physical need
of the program for which they are applying.
This evaluation is requested by sending a 3008 form that has been
completed and signed by the individual’s physician along with additional
medical records including medication list to the Department of Elder
Affairs. An assessor would then make
arrangements for an evaluation to be performed wherever the individual is
residing. The final report is then
provided to the Department of Children and Families, and added to the financial
documentation already sent in by the applicant and then the DCF caseworker is
able to open the benefits for which the applicant had applied if all
qualifications have been met.
If the individual had applied for nursing home Medicaid, the
effective date of the Medicaid approval would be the 1st of the
month that the application was submitted, providing the individual was eligible
beginning in that month. The waiver
programs are forward-moving programs in that benefit begins the 1st
of the following month after approval is granted and enrollment in a Medicaid managed care plan. The plan that is chosen would provide a case
manager who would contact the recipient and/or family to discuss the applicant’s
needs and plan of care. The case manager
would also remain involved in the client’s ongoing care needs.
In order to continue ongoing benefits, the applicant must
submit a renewal of benefits each year with the Department of Children and Families
and is also responsible for reporting any changes that occur along the way, such as changes in living arrangements, income,
expenses, assets, etc. The physical
level of care evaluation does not need to be repeated each year, only the
financial piece.
So, as you can see, the web of confusion that is created by
Florida’s Medicaid long term care system is forever in need of explanation. What I have provided here is a plethora of
information to comprehend and we are here for you to help you through this maze.
Christine Isenhour
President
Isenhour Senior Services
239-542-7366
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