Overview of the Statewide Medicaid Managed Care Long-Term Care Program
Florida’s Statewide Medicaid Managed Care (SMMC) Long Term Care (LTC) Waiver Program provides a variety of long-term care services and supports for elderly and disabled Florida residents who require a nursing home level of care. While nursing home care is a benefit available via this program, a variety of home and community-based services (HCBS) are also available to program beneficiaries in their home, the home of a loved one, an adult family care home, or an assisted living residence to prevent and delay the need for institutionalization (nursing home admission).
The benefits received vary based on the needs and circumstances of the program participant. For example, one might receive personal care assistance, homemaker services, and a personal emergency response system to promote independent living. In contrast, a program participant with an informal caregiver, such as a family member, might be eligible for adult day health care and respite care to supplement the care already being received by a family member.
SMMC LTC Program participants receive their long-term care benefits via a single Medicaid plan provided by a managed care organization (MCO), essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. Florida is divided into 11 regions, and within each region, SMMC LTC program participants have several long-term care managed care plans from which to choose.
There is some flexibility of providers for persons receiving care services via SMMC LTC, as some benefits, such as homemaker services and personal care, may be consumer directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Relatives, including spouses and adult children, can be hired. A financial management services agency handles the financial aspects of employment responsibilities such as background checks, tax withholding, and caregiver payments.
The SMMC LTC Waiver is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the waiver has a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.
SMMC LTC is authorized under a 1915(c) and 1915(b) Medicaid Waiver. Via the 1915(c) Waiver, home and community based services (HCBS) are provided. The 1915(b) Waiver requires the program’s services and supports be delivered via a managed care model. Florida’s SMMC LTC Program is part of the Statewide Medicaid Managed Care Program (SMMC). SMMC is made up of three parts: Long Term Care (which is covered on this page), Managed Medical Assistance (MMA), and Dental. Persons who receive SMMC LTC may also be eligible for the other parts of the program.
Benefits of the Statewide Medicaid Managed Care Long-Term Care Program
Follows is a list of the benefits available via the SMMC LTC Program. An individual care plan will determine which services and supports a program participant will receive. This means meeting waiver requirements does not guarantee receipt of all potential benefits. Some care services may be participant-directed, meaning the beneficiary is able to choose their care provider.
– Adult Day Health Care – Daytime supervision and personal care assistance in a group setting
– Assisted Living Services – Homemaker services, personal care assistance, and medication oversight
– Attendant Nursing Care – To assist persons in recovering from an injury or illness
– Behavior Management
– Caregiver Training
– Case Management
– Companionship Services – Supervision and limited assistance with tasks such as shopping for essentials, meal preparation, and laundry
– Home Modifications – For accessibility
– Home Meal Delivery
– Homemaker Services – Assistance with housecleaning and preparing meals
– Hospice Care
– Medical Supplies and Equipment
– Medication Administration & Management
– Nursing Home Care
– Nursing Services – Intermittent and Skilled
– Nutritional Assessment & Risk Reduction
– Personal Care Services – Non-medical assistance with personal hygiene, toileting, meal preparation, housework, etc.
– Personal Emergency Response System (PERS)
– Respite Care – In-home and out-of-home short-term care to alleviate a primary caregiver
– Therapies (occupational, physical, respiratory, speech)
While services can be provided in assisted living residences and adult family care homes / adult foster care, SMMC LTC will not cover the cost of room and board.
Eligibility Requirements for Statewide Medicaid Managed Care Long-Term Care Program
The SMMC LTC Program is for Florida residents who are elderly (65+) or younger if disabled (18+). Additional eligibility criteria are as follows:
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2022, an applicant, regardless of marital status, can have a monthly income up to $2,523. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,523 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. There is a minimum income allowance, set at $2,288.75 / month (effective July 2022 – June 2023), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,435 / month (effective January 2022 – December 2022). While this potentially allows a non-applicant a higher income allowance, the exact amount one can receive is dependent on their shelter and utility costs. However, a spousal income allowance can never push a non-applicant’s total monthly income over $3,435. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.
In 2022, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $137,400. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Florida Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $636,000 in 2022. Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative living in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC). For the SMMC LTC Waiver, the Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program determines if this level of care need is met. The AHCA 5000-3008 Form, “Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form”, is used. The ability / inability to complete activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting) is considered. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive issues, such as disorientation, or behavioral problems, like regular attempts to leave the facility, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC. One exception to the NFLOC requirement exists; Applicants who have Cystic Fibrosis must require the same level of care as provided in a hospital.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities that turns countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Florida to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program, preserving them for family as inheritance. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, such as the Modern Half a Loaf Strategy, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the Statewide Medicaid Managed Care Long-Term Care Program
Before You Apply
Prior to applying for the SMMC LTC Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Since the SMMC LTC Waiver is not an entitlement program, there may be a waitlist for program participation. This program is approved for approximately 68,700 beneficiaries per year. In the case of a waitlist, an applicant’s access to a participant slot is determined by an applicant’s priority score, which is based on frailty. To be clear, participant slots are not awarded based on the length of time one has been on the waitlist.
To begin the process of applying for long-term care benefits via Florida’s Statewide Medicaid Managed Care Program, one must contact their area’s Aging and Disability Resource Center (ADRC) for an over-the-phone screening. Contact information for ADRC’s by location can be found here. Alternatively, one can call the Elder Helpline at 1-800-963-5337. The pre-screening will take approximately 45-60 minutes and determines one’s priority score and waitlist placement for program participation.
When a participant slot becomes available, the applicant will be contacted and mailed Form 3008: Medicaid Certification for Medicaid Long-Term Care Services and Patient Transfer Form. This form must be filled out by one’s doctor and returned to the area’s ADRC. Upon return of this form, an in-person Comprehensive Assessment and Review for Long-Term Care Services (CARES) assessment will be completed.
If an applicant is not already on Medicaid, he/she will have to apply. This can be done online via ACCESS Florida. Applicants must check the box indicating that long-term care is needed. Persons should indicate whether nursing home care or home and community based services (HCBS) is required. In addition, persons can apply in-person at their local ACCESS Service Center or called the Customer Service Center at 850-300-4323 to request a paper application. The Customer Service Center can also answer questions and assist with the application process.
If an applicant is determined eligible for the SMMC LTC Program, managed care plan options will be received by mail.
Additional information about the SMMC LTC Program can be found on the AHCA website and the DOEA website. Persons can also contact the Elder Helpline at 1-800-963-5337. The Agency for Health Care Administration (AHCA) administers the SMMC LTC Program, the Department of Elder Affairs (DOEA) determines functional / medical eligibility, and the Department of Children and Families (DCF) determines financial eligibility.
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.