Florida's Medicaid Long-Term Care Managed Care Program

Florida has put its Medicaid-paid long-term care services into managed care.

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Paying for long-term care in Florida, whether it be a nursing home, assisted living facility, or home health care, is expensive. The average cost of a nursing home in Florida is $7,500 per month. Private health insurance policies generally don't pay for long-term care, and few people purchase long-term care insurance policies. For those covered by Medicare, long-term care services is very limited. In short, for Floridians needing long-term care, Medicaid is the most common source of funding. In 2012, nearly 70% of nursing home costs in Florida were paid by Medicaid.

Managed Long-Term Care in Florida

Because long-term care is so expensive and accounts for a large proportion of Florida's Medicaid expenditures, the state decided to transition long-term care recipients into a managed care system. The transition to the new Statewide Medicaid Long-Term Care Managed Care (LTCMC) program started in August 2013 and was completed on March 1, 2014. Across the country, states are moving Medicaid recipients into managed care because they expect that managed care will save money, in part by helping people stay out of nursing homes.

Currently, almost all Medicaid recipients in Florida who need long-term care services are required to enroll in one of Florida’s seven LTCMC plans. (A few exceptions are discussed below.) The plans are operated by private companies, mostly health maintenance organizations (HMOs). Every plan is not available in every part of the state.

All of the LTCMC plans must cover certain core services, including adult day care, assisted living facility and nursing facility care, caregiver training, case management, home accessibility adaptation, home-delivered meals, homemaker/chore services, hospice, nursing care, medical equipment and supplies, medication administration and management, personal care, personal emergency response systems, respite care, transportation, and occupational, speech, respiratory, and physical therapy.

Plans also offer different optional benefits. Examples are payment for the costs of moving home from a nursing home, payment for the cost of holding your bed at an assisted living facility while you are gone for a short time, and dental or vision services.

Keep in mind that individual service providers may have waiting lists. Just because the service is covered by your plan does not mean that the plan guarantees that you will find a provider to give you the service right away.

You can compare and choose Florida long-term managed care plans at the Florida Agency for Health Care Administration site. You can also get help from Medicaid Choice counselors either by phone or in person by calling (877) 711-3622.

Exceptions to Mandatory Managed Long-Term Care

There are very few exceptions to the mandatory enrollment requirement in managed long-term care in Florida (for those who want Medicaid-paid long-term care services).

Medicaid Waiver Programs

Some particular categories of individuals needing long-term care are not required to enroll in managed care, like those who had been participating in Medicaid Waiver programs for individuals with developmental disabilities, traumatic brain and spinal cord injuries, or cystic fibrosis.

Program for All-Inclusive Care for the Elderly (PACE)

Those who are enrolled in a Program for All-Inclusive Care for the Elderly (PACE) are not required to enroll in a managed long-term care program. PACE programs offer coordinated services with a goal of keeping seniors who are at risk of needing to be institutionalized a nursing home in their own homes or in less restrictive facilities. Florida has PACE programs only in Pinellas, Lee, Collier, Charlotte, Palm Beach, and Miami-Dade counties. Statewide, fewer than 1,000 people are enrolled in PACE.

To participate in a PACE program, you must be 55 or older, you must meet the nursing home level of care, and you must be able to live safely in the community with appropriate services. PACE offers medical care, therapy services, transportation, activities and social work services, and home health services. PACE programs can offer services to those who are over-income for Medicaid, and they can charge fees to participate for those who do not receive Medicaid.

Long-Term Care Managed Care Plan Obligations

Consumer advocates worry that Medicaid recipients will lose some benefits in managed care because plans have an incentive to cut costs to increase their profits. Florida has implemented some protections for recipients during the transition to managed care. First, plans are required to develop a care plan for each beneficiary within five to seven days of enrollment. The care plan is supposed to set out what services you need and where you will get them from. LTCMC plans must continue to pay for the service providers that you have been using, for up to 60 days, even if those service providers have not contracted with the plan and so would not ordinarily be available to you.

Florida has also required all nursing homes to have the option of being included in all LTCMC plans for the first year, so that residents would not have to be forced to move right away just because their plan did not cover their nursing home.

LTCMC plans must give you notice of your right to a fair hearing to contest its decisions. If you disagree with a decision that your LTCMC plan makes, you can file for a fair hearing by calling (850) 488-1429; faxing (850) 487-0662; writing to Department of Children and Families, Office of Appeal Hearings, Building 5, Room 255, 1317 Winewood Blvd., Tallahassee, FL 32399-0700; or emailing Appeal_Hearings@dcf.state.fl.us.

Changing Long-Term Care Managed Care Plans

Florida gave recipients of long-term care services a chance to choose a long-term care plan in their region. If a recipient didn't choose, the state assigned a plan.

You can change plans within the first 90 days after you enroll in the plan, or in the annual 60-day open enrollment period. If you want to change plans at another time, you must show that you have good cause. Some good cause reasons include that the plan doesn’t provide good care, or that the plan doesn’t offer services from a provider that you have used in the past.

Read on to find out about qualifying for a nursing home, assisted living facility, or home health care through Florida's Medicaid managed care plans.

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