When Medicaid in Florida Will Pay for a Nursing Home, Assisted Living, or Home Health Care

Florida Medicaid provides services to eligible residents through several programs:

• Medicaid for nursing home stays
• the Statewide Medicaid Managed Care (SMMC) long-term care (LTC) program, and
• Medicaid for aged and disabled (MEDS-AD) programs.

Florida Medicaid plans cover a range of long-term care services, including certain costs of nursing facility care and assisted living facility care, homemaker and chore services, nursing care, medical equipment and supplies, and other services, for those who qualify.

There are two parts to qualifying for Florida nursing home Medicaid or SMMC-LTC coverage: needing a nursing home level of care and financial eligibility.

Nursing Home Level of Care and Medical Necessity in Florida

To qualify for Florida's nursing home Medicaid and SMMC-LTC programs, you must require a nursing home "level of care." That means that you must be able to show that your condition is serious enough that you either:

• need to be in a nursing home, with the availability of round-the-clock nursing care, or
• would need to be in a nursing home if you weren't receiving supportive long-term care services.

Although SMMC-LTC coverage may be available for certain limited long-term care services like personal care assistance or adult day care, you must require a nursing home level of care to be eligible for institutional nursing home or home and community-based services (HCBS).

Comprehensive Assessment and Review for Long-Term Care Services (CARES) is Florida's screening program for long-term care applicants. CARES assessments are administered by the Department of Elder Affairs (DEA). Someone from DEA will personally interview you and ask you many questions about your ability to function, the help you need, and your medical conditions. You will need a CARES assessment to show that you meet the nursing home level of care necessary to qualify for Florida's managed long-term care programs.

Once you show that you require a nursing home level of care and you enroll in a Medicaid plan, you'll need to establish that the service you want is "medically necessary" (for instance, necessary to prevent serious disability). Nursing home Medicaid and SMMC-LTC plans will pay only for services that are medically necessary.

The CARES assessment, along with input from your treatment providers, will help your plan determine whether the particular long-term care service that you want is medically necessary.

Financial Eligibility for Florida Nursing Home and Managed Long-Term Care

Even if you meet the nursing home level of care (and are 18 or over), you can qualify for Florida's nursing home Medicaid or SMMC-LTC programs only if you meet the Florida Medicaid income limits for long-term care, as well as the Medicaid resource limits for long-term care. Different limits apply for MEDS-AD eligibility.

Income Limits for Medicaid-Paid Long-Term Care in Florida

If you qualify for SSI, you're already eligible for long-term care through Medicaid in Florida. If not, your monthly income (in 2024) must be no more than $2,829, or $5,658 for spouses who are both trying to qualify for Medicaid-paid long-term care.

If you are or will be moving to a nursing home, you'll be required to contribute most of your income to your care. However, you're allowed to keep a small amount of money, called a "personal needs allowance" (PNA). In 2024, Florida's personal needs allowance for nursing home residents is $160 per month. (There is a separate maintenance allowance for spouses who remain at home.)

Florida does have a Medically Needy program, which assists individuals who have too much income to qualify for Medicaid. The Medically Needy, or "share of cost," program lets enrolled participants contribute part of their monthly income towards allowable medical expenses, similar to meeting an insurance deductible, to gain Medicaid eligibility for the month. Once participating individuals "spend down" their income through their sharing of medical costs, Medicaid can cover medical expenses during the monthly period.

Florida also allows individuals to establish special trusts, called Qualified Income Trusts, Qualified Disabled Trusts, or Qualified Pooled Trusts for the Disabled, to set aside excess income and still qualify for Medicaid. You can learn more about these trusts in Nolo's article on Medicaid special needs trusts (for specific information about trusts, consult an attorney).

Asset Limits for Medicaid Long-Term Care

In addition, to qualify for the nursing home Medicaid or SMMC-LTC programs in Florida, you must have few assets, like money in the bank, retirement accounts, land, or personal property like cars. The resource (asset) limit for a single person to qualify for Medicaid in Florida in 2024 is $2,000, and it's $3,000 for a married couple. Some property doesn't count toward the resource limit, like the value of your home (up to $713,000 in 2024) if your spouse lives there or if you intend to return there. There are other excluded resources, like the value of one car.

There is a separate "community spouse resource allowance" (CSRA), an amount that a spouse who does not need Medicaid long-term care services can retain. In 2024, the community spouse resource allowance in Florida is $154,140 in assets.

Medicaid for Floridians Needing Assisted Living Facilities

A Florida assisted living facility (ALF) provides room, board, and personal care services, such as help with dressing, moving, bathing, taking medication, and general care of your physical and mental wellbeing. Another kind of ALF is an adult family care home (AFCH). AFCHs have no more than five residents, and the operator of the home must live in the home.

Assisted living facilities and adult family care homes can be covered by Florida's SMMC-LTC plans. Each plan will contract with its own providers, so not every ALF or AFCH will be covered under every plan. It is important to choose the plan that covers the facility you're in or that you want to enter.

The average cost of assisted living in Florida was about $4,000 a month in 2021. While Florida's Medicaid program won't pay for all of an assisted living facility's cost, it might reduce the amount significantly.

Florida also has a non-Medicaid program called Optional State Supplementation (OSS) that helps low-income qualified individuals pay for room and board at ALFs and AFCHs. For more information, visit the website of Florida's Department of Children and Families.

Medicaid for Floridians Needing Home Health Care

Home health care can include:

• skilled nursing or therapy services
• home health aide services like medication management or bathing assistance, and
• personal care aide services like meal preparation or cleaning.

SMMC-LTC plans offer home health services as part of their benefit packages, so if you're a participant in such a plan you can receive assistance from skilled nurses, home health aides, or personal care attendants in your home, as long as your doctor or care coordinator has authorized those services for you and they're medically necessary for the treatment of a specific impairment.

Coverage through MEDS-AD may also be available for assistance with activities of daily living even if a nursing facility level of care is not required.

Florida Managed Long-Term Care Plans

Because long-term care is so expensive and accounts for a large proportion of Florida's Medicaid expenditures, the state transitioned long-term care recipients into a managed care system consisting of eleven regions and various SMMC plans that serve them. As a result of a more recent 2022 legislative change, Florida counties will be consolidated into a reduced nine regions, effective 2025.

Not every SMMC-LTC plan is available in every part of the state. All of the plans must cover certain core services, including:

• nursing care
• adult day care
• assisted living facility and nursing facility care
• caregiver training
• case management
• home accessibility adaptation
• home-delivered meals
• homemaker and chore services
• hospice
• medical equipment and supplies
• medication administration and management
• personal care
• personal emergency response systems
• respite care
• transportation, and
• occupational, speech, respiratory, and physical therapy.

You can compare and choose Florida SMMC-LTC plans at the Florida Agency for Health Care Administration site. You can also get help from Medicaid Choice Counselors by calling (877) 711-3662.

_{Updated January 26, 2024}