Page Reviewed / Updated - Jan. 2019
In 2013, Florida deployed a Statewide Medicaid Managed Care Long-Term Care Program (SMMC LTC) system, also referred to as a nursing home diversion program, to meet the needs of their elderly residents. Under this program, Medicaid eligible seniors who require long term care supports can receive assistance in their home, in the community, or in assisted living. SMMC LTC divides Florida into 11 regions with six different Managed Health Care Organizations that provide services. Not every provider is available in all 11 regions.
How it Works for Families
Needy seniors who require care and are financially eligible, select a "Plan" from one of the providers who offer care in their geographic area. That provider becomes responsible for all of the participant's long term care needs. Participants still receive their medical services coverage through Medicare or another private insurance policy. Counselors are available to help participants choose a long term care plan.
Having selected a Plan, each participant is assigned a Long Term Care Case Manager who conducts a comprehensive assessment of his/her care needs. Family members and other persons knowledgeable about the participant can (and should) participate in the assessment process. The outcome of the assessment is a Care Plan that states the least restrictive environment in which the participant can receive care (for example at home, in adult day care, assisted living, an adult family care home, or a nursing home) and what care and supports they require in that environment. A complete list of potential services is available in the benefits section below.
The Plan has a network of care and service providers to fulfill all the needs of the participants. Nevertheless, each Plan offers clients a degree of ‘participant direction.’ This Participant Directed Option (PDO) means program participants have some choice in who provides them with care services, at a minimum in the areas of personal care and homemaker services. Program participants, or a representative chosen by the program participant, such as a friend or relative, are able to hire, train, and manage the care provider. Family members, including adult children and even spouses, can be hired and receive compensation as providers. Some readers in Florida may know of PDO by other names including Cash & Counseling or Consumer Directed Care.
If a program participant believes they require a level or type of care or support service is required for which he/she has not been approved in his/her Care Plan, they can request a Medicaid fair hearing can be requested in which a third-party organization handles his/her dispute with the Managed Care Organization.
To receive services under SMMC LTC, candidates must meet all the following criteria:
Many families often misunderstand exactly what the state means when they use the term "nursing facility level of care." This does not necessarily mean that the care recipient requires nursing or skilled medical services. Florida uses a standardized in-person exam to understand the degree to which the applicant needs assistance or partial assistance to complete two or more of activities of daily living. Examples include bathing, personal hygiene, eating, and mobility. In the case of Alzheimer’s and dementia care patients who do not have any physical limitations, the state also recognizes the need for supervision of individuals who have several memory impairments.
Financial eligibility is complicated. The state considers both the applicant's income and assets. In 2019, the individual limit for an applicant is $2,313 per month. For couples, when both parties are applying, the joint income limit is $4,626 / month. When only one spouse applies and the other does not, the couple has more options to qualify with regards to their income. The spouse who needs the care has the income limit as an individual applicant. The spouse who is not applying is permitted to keep sufficient income from the applicant spouse to enable her or him to continue living independently. In this situation, couples can allocate their joint income to the healthy spouse and help the spouse that requires assistance to qualify for Medicaid. This is called the monthly maintenance needs allowance, and as of 2019, allows an applicant spouse to transfer as much as $3,160.50 / month to his/her non-applicant spouse.
The asset limit for a single applicant is $2,000, and the limit for a married couple, with both spouses applying, is $3,000. In situations where there is both an applicant spouse and a non-applicant spouse, different rules apply. As of 2019, a non-applicant spouse can retain up to $126,420 of the couples joint assets. This is called the community spouse resource allowance and is also intended to prevent the healthy spouse from becoming impoverished. Please note: Certain assets are considered exempt, or said another way, non-countable towards Medicaid eligibility. For instance, one’s home, given the applicant or their spouse lives in it and the equity value is under $585,000 (in 2019). Other exempt items include a vehicle, household belongings, personal items, such as one’s wedding ring, and burial plots.
Persons whose assets or incomes exceed the Medicaid limits or couples where only one spouse requires Medicaid should strongly consider finding Medicaid planning. Doing so helps to ensure participants qualify and that their healthy spouses have adequate income and resources to continue living independently. Find assistance applying for Medicaid.
The following list is comprehensive of what is offered under the Florida Statewide Medicaid Managed Care, Long Term Care Program. Not every participant is eligible for all the following services. Those services marked with asterisks* can be participant directed.
When the applicant senior is not in a nursing home, the application process starts with a call to the Florida senior’s local Area Agency on Aging. One can also call the Elder Helpline at 800-262-2243. Callers should request a “screening for home and community based services.” The representative schedules a time for the phone screening with the primary caregiver or closest family member, usually one to two weeks out. The screening interview typically lasts 30 to 40 minutes. The interview covers basic demographic information for the applicant as well as his/her income and assets. The interview mostly asks about the elder’s needs for care, including his/her ability to perform Activities of Daily Living.
Following the interview, the elder receives a prioritization decision. This letter indicates whether services can commence immediately or whether the senior needs to be waitlisted. If the senior is prioritized for home or community (assisted living) supports to start immediately, he/she must apply to the Department of Children and Family Services through the ACCESS System (online application) for their formal Medicaid approval.
To learn more about SMMC LTC, click here.