When Medicaid in Florida Will Pay for a Nursing Home, Assisted Living, or Home Health Care
(Page 2 of 2 of Florida's Medicaid Long-Term Care Managed Care Program)
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Florida's Medicaid Long-Term Care Managed Care (LTCMC) plans cover the costs of assisted living facility and nursing facility care, homemaker/chore services, nursing care, and medical equipment and supplies for those who qualify. (Learn more about Florida's new LTCMC program in Nolo's article on Florida's Medicaid Long-Term Care Managed Care program.)
There are two parts to qualifying for a LTCMC plan: needing a nursing home level of care and financial eligibility.
Nursing Home Level of Care and Medical NecessityTo qualify for Florida's LTCMC program, 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 were not receiving supportive long-term care services.
Comprehensive Assessment and Review for Long-Term Care Services (CARES) is Florida’s screening program for long-term care applicants. CARES assessments are done by the Department of Elder Affairs. Someone 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 managed care plan, you will need to show that the service you want is medically necessary. Managed care plans will only pay for services that are medically necessary. In Florida, medically necessary means that the service:
- is necessary to protect life, to prevent significant illness or disability, or to alleviate severe pain
- is consistent with symptoms of the illness or injury under treatment
- is consistent with generally accepted professional medical standards
- reflects the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available in the state, and
- furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.
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 for you.
Financial Eligibility for Managed Long-Term Care in Florida
Even if you meet the nursing home level of care (and are 18 or over), you can qualify for Florida’s managed long-term care program only if you meet the income and resource limits.
If you receive SSI, you are already eligible. Otherwise, your monthly income in 2014 must be no more than $2,163, or $4,326 for a couple who are both trying to qualify for Medicaid-paid long-term care.
If you are or will be moving to a nursing home, you will be required to contribute most of your income to your care. You are allowed to keep a small amount of money, called a “personal needs allowance” (PNA). In 2014, Florida’s PNA for nursing home residents is $35 per month. (There is a separate maintenance allowance for spouses who remain at home.)
Florida 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 information about pooled income trusts, consult an attorney.
Florida does have a medically needy program, in which individuals who have too much income to qualify for Medicaid can contribute part of their income towards their medical expenses each month to get Medicaid to pay the remainder. However, this program, also known as Florida’s “share of cost” program, does not pay for any long-term care services.
In addition, to qualify for Medicaid in Florida, you must have few assets, like money in the bank, retirement accounts, land, and personal property like cars. The resource (asset) limit for a single person to qualify for Medicaid in Florida in 2014 is $2,000, and it is $3,000 for a married couple when both spouses want to qualify. Some property does not count toward the resource limit, like the value of your home 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); a spouse who does not need Medicaid long-term care services can retain about to about $120,000 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.
ALFs and AFCHs can be covered by Florida’s LTCMC plans. Each LTCMC 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 are in or that you want to enter.
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. You must apply through 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.
LTCMC plans offer home health services as part of their benefit package, so if you are a participant in a LTCMC 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 are medically necessary for treatment of a specific impairment.
Programs for All-Inclusive Care for the Elderly (PACE) also offer these same home health care services. Learn about PACE programs in the first page of this article, on Florida Medicaid LTMC plans.
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