FL Medicaid Managed Care or Florida Statewide Medicaid Managed Care Long-Term Care (SMMC LTC) is a program that was first implemented in 2013 to meet the needs of Florida’s elderly residents who require Nursing Facility Level Of Care (NFLOC). The following criteria are considered when determining the NFLOC requirements:
- Physical Functional Ability
- Health Issues/Medical Needs
- Cognitive Impairment
- Behavioral Problems
It is worth noting that the term nursing facility level of care does not necessarily mean that the care recipient requires nursing or skilled medical services. In Florida, a standardized in-person exam is conducted to determine how much assistance or partial assistance a senior citizen needs to complete two or more Activities of Daily Living (ADLs).
Using FL Medicaid Managed Care
Long term care is something the state of Florida takes very seriously, which is why you will find a multi-agency effort on FL Medicaid Managed Care. The Agency for Health Care Administration (AHCA) implements the Statewide Medicaid Managed Care (SMMC) program and sets coverage policies and enrolls those that are eligible into an LTC plan.
The Department of Children and Families (DCF) is charged with determining an individual’s financial eligibility for long term care services. Meanwhile, the Department of Elder Affairs (DOEA) determines an individual’s medical eligibility and the level of care needed.
Recently, Health News Florida reported on companies being hit with dozens of complaints. In response, Florida Medicaid officials assessed more than $1 million in damages against all 11 managed health care plans that have contracts with the state. Again, this serves to highlight the importance of abiding by state regulations.
4 Easy Steps To Obtaining FL Managed Care
- Check Your Eligibility
For seniors or individuals who want to receive services under FL Medicaid Managed Care, they must meet certain requirements, which are that they:
- Must be a legal Florida resident
- Must be a minimum of 65 years of age, or between 18 and 64 years old and designated as disabled as stated by the Social Security Administration
- Must need “nursing facility level of care”
- Must meet the financial requirements for Florida Medicaid:
Aging Care provides a one caregiver’s journey to meeting Medicaid’s financial requirements for her aunt, who, along with her uncle had too much income to qualify for Medicaid.
They had to embrace a strategy called spending down, or, as U.S. News explains, counting some of that monthly income that is too high to be eligible for Medicaid toward:
- Medical bills, past and current.
- Transportation services to get medical care
- Home improvements to help with medical care, like a chair-lift
- Medical expenses, such as eyeglasses or a hearing aid
In this particular case, the elderly woman canceled a life insurance policy that had a face value of $5000, decreased the coverage of another insurance policy to the Medicaid $1500 limit, and counted other acceptable spend-down expenses against her income, such as medications, eyeglasses, hearing aids, and nursing home purchases to make her stay cozier. The husband of the author’s aunt, meanwhile, had to spend down on his income, selling his house and buying into a Continuing Care Retirement Community (CCRC).
Monthly Income Limits for Medicaid
The reason spending down becomes necessary is that, in 2021, an applicant is allowed a maximum income of up to $2,382/month. If the applicant is married, they also have a maximum income of $2,382/month if one spouse is applying. If both spouses are applying, they have an income limit of $4,764/month, with each spouse being allowed a max income of $2,382/month. Meanwhile, if you have a home, it is worth noting that Medicaid requires a home to be valued at $603,000 or less to qualify.
By selling his house, the uncle was able to show that he and his wife’s medical expenses had canceled out his surplus income (he had to sell his house to afford the CCRC). Hence, they qualified for Medicaid.
The American Council on Aging provides the following income limit table:
If a person’s income is over the Medicaid limit, they can make use of a qualified income trust. By depositing excess income in the trust, it no longer counts as income, and they can now qualify for Medicaid. Also, suppose they surpass the Medicaid asset threshold. In that case, they can employ other Medicaid planning techniques as stated by Medicaid Planning assistance.
If seniors want to check their eligibility quickly, Medical Planning Assistance provides a free, online Medicaid eligibility test.
- Apply For FL Managed Care
- Ensure that you have the following documents:
- Social Security Card
- Medica Card
- Proof of income
- Bank Statements of up to 60 months prior to application
- Life insurance Policy Copy
- Property Deeds
- Pre-need burial contracts
- Call your local Area Agency on Aging or the Aging and Disability Resource Centre (ADRC) helpline, whose number is listed by county here.
- Make a request for “screening for home and community-based services.”
- A phone screening will be scheduled with the primary caregiver of a close family member.
- Note that an AHCA Form 3008 will then be sent to the applicant. It is used by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program to help determine medical eligibility for Medicaid Waiver programs.
- The screening call will happen after approximately two weeks (from the initial call) and lasts for 30 to 40 minutes.
- The interviewer will request demographic information about the applicant as well as information about their income and assets. These are all required to qualify for FL Medicaid Managed Care.
- The interviewer will also ask questions about the applicant’s needs for care as well as their ability to perform ADLs (Activities of Daily Living), which become more difficult with age and are one of the focuses of assisted living care.
- After the interview, the applicant will receive a priority decision which indicates whether the applicant will immediately begin to receive services or whether they are on a waitlist for their Florida Medicaid health plans
- Should the applicant be prioritized for immediate home or assisted living, they must apply to the Department of Children and Family Services through the Access System for their formal Medicaid approval.
- Alternatively, you can go to the FLManagedCare Website and apply from there.
- Also, check the AHCA Florida website to locate all approved facilities.
- Check Plans Offered Under FL Medicaid Managed Care
- Providers who offer senior care in the geographical area will provide a page on their website where seniors or their adult children can select a plan.
- Once a plan is selected, a long term care case manager is assigned to the senior citizen. This individual will assess the individual’s care needs and determine the least restrictive environment where the senior citizen can receive care.
- After the assessment, environments that could be chosen include an adult daycare, nursing home, or assisted living facilities.
- During the plan selection and the assessment phase by the long term care case manager, it is advised that adult children be present.
- Each plan offers senior citizens a degree of Participant Directed Option (PDO), which means participants can choose who provides them with care (friends or relatives included) in personal care and homemaker services. PDO is also known as Cash & Counseling or Consumer Directed Care.
- Family members can be hired and receive compensation as caregivers. That includes adult children and even spouses.
- Through Florida Medicaid, seniors may also receive Managed Medical Assistance (MMA), which provides Medicaid-covered medical services like doctor visits, hospital care, prescribed drugs, mental health care, and transportation to these services.
- One can request a Medicaid fair hearing if they want to be approved for a type of care they believe is necessary.
The AHCA provides a three-step graphic to help with getting Medicaid:
- Check The Benefits and Services Offered by FL Medicaid Managed Care
Below is a list of all the benefits and services offered by FL Medicaid Managed Care, as stated by Medical Planning Assistance. It is worth noting that individuals may not be eligible for all the listed services. Also, services listed with an asterisk (*) can be participant-directed, meaning the beneficiary is able to choose their care provider:
Adult companion care*
Adult day health care
Adult family care home / adult foster care
Assistive care services
Assisted living residence services
Attendant nursing care*
Care coordination / case management
Home accessibility adaptation
Intermittent and skilled nursing*
Medical equipment and supplies
Nutritional assessment/risk reduction
Personal emergency response system
Therapies (occupational, physical, respiratory, and speech)
Applying for FL Medicaid Managed Care Is Easy But Should Be Done Immediately
Seniors who follow the above steps are likely to get FL Medicaid Managed Care. However, FL Managed Care has a limit on the number of persons who can receive assistance simultaneously. The situation has gotten dire that Forbes published an article arguing why Florida may be the worst state for long term care.
One of the reasons for this is because Florida nursing homes are very pricy. The state ranks 39th for the cost as a percentage of median household income for 65+ people. Also, Medicaid Waiver states that the waitlist can be as long as seven or more years before getting waiver services in Florida. This is something families of senior citizens should take into account as they apply. Though not perfect for Florida residents, Florida Medicaid health plans help lower the cost of health for seniors and relieve the burden on adult children of taking care of their parents.