Florida Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Florida Medicaid Long Term Care, which is different from regular Medicaid. Medicaid will help pay for long term care for Florida residents in a nursing home, in their home and in other residential settings through one of three programs – Nursing Home / Institutional Medicaid, Statewide Medicaid Managed Care and Medicaid for Aged and Disabled.

 

Florida Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Medicaid will cover the cost of long term care in a nursing home for eligible Florida residents through its Nursing Home / Institutional Medicaid. This includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with Activities of Daily Living (eating, bathing, moving, dressing and using the bathroom).

Some of the things that Florida Medicaid won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Any Florida Medicaid beneficiary who receives Nursing Home Medicaid coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $130 / month. This can be spent on any personal item – clothes, snacks, books, haircuts, cell phones, etc. It cannot be spent on any item that Medicaid covers, including hygiene basics like toothbrush, soap, deodorant, razors and incontinence supplies, unless the Medicaid beneficiary wants a specific brand that is not covered by Medicaid. In this case, they could spend their personal needs allowance on the item.

 

Statewide Medicaid Managed Care (SMMC) Program

Florida’s Statewide Medicaid Managed Care (SMMC) Program will pay for goods and services that help Florida Medicaid recipients who require a Nursing Facility Level of Care remain living “in the community” instead of living in a nursing home. Living “in the community” can mean living in their home, the home of a loved one, an adult family care home or an assisted living residence. The goods and services provided by the SMMC Program can be medical (skilled nursing care, physical therapy, durable medical equipment or prescription medication) or non-medical (like adult day care, transportation, housekeeping, and personal care assistance with Activities of Daily Living such as getting out of bed, dressing, eating, bathing and toileting). While SMMC Program benefits can include nursing home care, the program’s primary purpose is to delay nursing home placement by providing care in the community.

The benefits delivered by the SMMC Program will vary depending on the needs and circumstances of each SMMC Program participant. Individuals will receive their benefits through a single plan from a managed care organization (MCO) and its network of healthcare providers. However, some of the non-medical benefits, like personal care and housekeeping, can be consumer directed, which means the program participant can have someone of their choice (including family members) provide, and get paid for providing, those benefits.

Unlike Florida’s Nursing Home Medicaid, the SMMC Program is not an entitlement. This means that even if a person is eligible for the SMMC Program and applies for it, they are not guaranteed to receive the benefits. So, if the SMMC program has reached its maximum number of participants (which is approximately 68,700 in 2022), a newly accepted applicant for the program will be put on a wait list until a spot in the program becomes available.

The SMMC Program replaced Home and Community Based Service (HCBS) Waivers in Florida.

 

Medicaid for Aged and Disabled (MEDS-AD) / Regular Medicaid

Florida’s Medicaid for Aged and Disabled (MEDS-AD), also called SSI-Related Medicaid or Regular Medicaid, covers low-income Florida residents who are aged (65 and older) or disabled and live “in the community.” Living “in the community” can mean living in their home, the home of a loved one, an adult family care home or an assisted living residence. Like Nursing Home Medicaid, Florida’s MEDS-AD is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.

Medicaid for Aged and Disabled (MEDS-AD) offers a variety of long term care benefits and services including adult day care, doctor’s visits, skilled nursing care, in-home personal care, prescription assistance and transportation, but the beneficiary qualifies for these benefits and services one at a time. That’s different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. This can work for MEDS-AD Medicaid recipients because they are not all required to need a Nursing Facility Level of Care (NFLOC) to qualify. Instead, MEDS-AD recipients will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.

Program of All-Inclusive Care for the Elderly (PACE)
Florida Medicaid’s Program of All-Inclusive Care for the Elderly coordinates medical, social service and non-medical personal needs of Medicaid for Aged and Disabled (MEDS-AD) beneficiaries into one comprehensive plan and delivery system. PACE is intended to help Florida residents who need a Nursing Facility Level of Care but want to keep residing and receiving care in their home or somewhere else in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs.

 

Eligibility Criteria For Florida Medicaid’s Long Term Care Programs

To be eligible for Florida Medicaid, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Statewide Medicaid Managed Care and Medicaid for Aged and Disabled (MEDS-AD) / Regular Medicaid.

  The easiest way to find the most current Florida Medicaid eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

Florida Medicaid Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Florida residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Nursing Home Medicaid recipients are only allowed to keep a $130 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.

For married applicants with both spouses applying, the 2022 asset limit for Nursing Home Medicaid through Florida Medicaid is $3,000 combined between the two applicants/spouses and the income limit is $5,046 / month combined. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, and the income limit is $2,523 / month for the applicant. The income of the non-applicant spouse is not counted.

Florida Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Florida Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Florida Medicaid’s Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

Florida’s Statewide Medicaid Managed Care Program Eligibility Criteria

Financial Requirements
Florida residents have to meet an asset limit and an income limit and in order to be financially eligible for the Statewide Medicaid Managed Care (SMMC) Program. For a single applicant in 2022, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $2,523 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2022 asset limit for the SMMC Program is $3,000 combined between the two applicants/spouses, and the income limit is a combined $5,046 / month. For a married applicant with just one spouse applying for the SMMC Program, the applicant spouse has a $2,000 asset limit and a $2,523 / month income limit for 2022, and the non-applicant spouse has a $137,400 asset limit and no income limit.

Florida Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Florida Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Florida’s Statewide Medicaid Managed Care (SMMC) Program is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if the applicant needs this level of care, Florida uses its Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program, and the AHCA 5000-3008 Form, “Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form.”

 

Florida’s Medicaid for Aged and Disabled Eligibility Criteria

Financial Requirements
Florida residents have to meet an asset limit and an income limit in order to be financially eligible for Medicaid for Aged and Disabled (MEDS-AD) / Regular Medicaid. For a single applicant in 2022, the asset limit is $5,000, which means they must have $5,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $997 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2022 asset limit for MEDS-AD Medicaid is $6,000 combined between the two applicants/spouses, and the income limit is a combined $1,343 / month. These limits are used for both married couples with both spouses applying for MEDS-AD Medicaid and married couples with only one spouse applying.

Functional Requirements
The basic functional requirements for Medicaid for Aged and Disabled (MEDS-AD) / Regular Medicaid are being disabled or aged (65 or over). Florida Medicaid will conduct an assessment of MEDS-AD Medicaid applicants and their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) to determine the kind of services the beneficiary needs and the state will cover.

 How Florida Medicaid Counts the Home
One’s home is often their most valuable asset, and if counted towards Florida’s Medicaid’s asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest is less than $636,000 (as of 2022), then the home is exempt from the asset limit. Home equity interest is portion of the home’s equity value that the applicant owns, and the home’s equity value is the current value of the home minus any outstanding mortgage / debt against the home. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $636,000. These rules apply to all three types of Medicaid.

 

Applying For Florida Medicaid Long Term Care Programs

The first step in applying for a Florida Medicaid Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home / Institutional Medicaid, Statewide Medicaid Managed Care and Medicaid for Aged and Disabled / Regular Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Florida Medicaid when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Florida Medicaid applicant. These documents will be needed for the official Florida Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, individuals can apply through the state’s ACCESS website. For help with this process, individuals can call the ACCESS Customer Call Center at 866-762-2237, or they can contact their local ACCESS Service Center.

Applying to the Statewide Medicaid Managed Care Program
To apply for Florida’s Statewide Medicaid Managed Care (SMMC) Program, individuals first need to be on Florida Medicaid. If they are not, they can apply through the state’s ACCESS website. Once an individual is enrolled in Medicaid, the next step in applying for the SMMC Program is contacting their local Aging and Disability Resource Center for a screening over the phone. To find your local Aging and Disability Resource center, go to this Department of Elder Affairs webpage. One can also call the Elder Helpline at 1-800-963-5337 for assistance with this application process.

Once the application is received, it will usually take 45-90 days to be reviewed and approved or denied by the state. It’s also possible applications that are missing information or have mistakes will be returned.

 

Choosing a Florida Medicaid Nursing Home

After an applicant has been approved for Nursing Home Medicaid through Florida Medicaid, they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, Florida Medicaid will only cover stays and care in approved nursing homes. Florida’s Agency for Health Care Administration provides a Nursing Home Guide that will help individuals find and compare nursing homes in the state. Nursing Home Compare is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.