Florida Medicaid Definition
Medicaid is a wide-ranging, federal, health care program for low-income individuals of any age. However, this page is specifically focused on Medicaid eligibility for Florida residents who are 65 years of age and older. The focus will also be on long term care, whether that be at home, in a nursing home, adult foster care, or in assisted living. Make note, Medicaid in Florida is sometimes referred to as the Statewide Medicaid Managed Care (SMMC) program. The Medicaid managed care program for long-term care services for the elderly and disabled is called the Long-term Care (LTC) program. All other health care services outside of long-term care are provided via the Managed Medical Assistance (MMA) program.
Income & Asset Limits for Florida Eligibility
There are several different Medicaid long-term care programs for which Florida seniors may be eligible. These programs have slightly different eligibility requirements and benefits. Further complicating eligibility are the facts that the criteria vary with marital status and that Florida offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – is an entitlement, which means that anyone who is eligible will receive assistance. Benefits are provided only in nursing homes.
2) Home and Community Based Services (HCBS) – In the past, Florida has offered HCBS Medicaid waivers for the aged, but no longer does. Instead, long-term care services are provided at home, adult day care, adult foster care homes, and in assisted living residences via a managed care system, which allows program participants to receive all Medicaid benefits via one administering agency. Unlike with waivers, the managed care program does not limit the number of participants, which means anyone who meets the eligibility requirements will receive assistance.
3) Regular Medicaid for Aged and Disabled (MEDS-AD) – is an entitlement, meaning all persons who are eligible will receive services. Benefits are provided at home or adult day care.
Eligibility for these programs is complicated by the facts that the criteria vary with marital status and that Florida offers multiple pathways towards eligibility. The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a Florida Medicaid program. Alternatively, one may opt to take the Medicaid Eligibility Test. IMPORTANT: Not meeting all the criteria below does not mean one is not eligible or cannot become eligible for Medicaid in Florida. More.
|2019 Florida Medicaid Long Term Care Eligibility for Seniors|
|Type of Medicaid||Single||Married (both spouses applying)||Married (one spouse applying)|
|Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required|
|Institutional / Nursing Home Medicaid||$2,313 / month||$2,000||Nursing Home||$4,626 / month (Each spouse is allowed up to $2,313 / month)||$3,000||Nursing Home||$2,313 / month for applicant||$2,000 for applicant & $126,420 for non-applicant||Nursing Home|
|Home and Community Based Services||$2,313 / month||$2,000||Nursing Home||$4,626 / month (Each spouse is allowed up to $2,313 / month)||$3,000||Nursing Home||$2,313 / month for applicant||$2,000 for applicant & $126,420 for non-applicant||Nursing Home|
|Regular Medicaid / Aged Blind and Disabled||$891 / month||$5,000||None||$1,208 / month||$6,000||None||$1,208 / month||$5,000||None|
What Defines “Income”
For Medicaid eligibility purposes, any income that a Medicaid applicant receives is counted. To clarify, this income can come from any source. Examples include employment wages, alimony payments, pension payments, Social Security Disability Income, Social Security Income, IRA withdrawals, and stock dividends. However, when only one spouse of a married couple is applying for Medicaid, only the income of the applicant is counted. Said another way, the income of the non-applicant spouse is disregarded. (Click here for additional information). There is also a Minimum Monthly Maintenance Needs Allowance (MMMNA), which is the minimum amount of monthly income to which the non-applicant spouse is entitled. As of July 2019, this figure is $2,113.75 / month and is set to increase again in July 2020. That said, this spousal allowance may be as high as $3,161 / month (this figure is effective January 2019 through December 2019) and is based on one’s shelter and utility costs. This rule allows the Medicaid applicant to transfer income to the non-applicant spouse to ensure he or she has sufficient funds with which to live. Please note that the monthly maintenance needs allowance is only relevant for married couples with one spouse applying for institutional Medicaid or home and community based services. Stated differently, when only one spouse is applying for regular Medicaid, the applicant spouse cannot transfer income to their non-applicant spouse.
What Defines “Assets”
Countable assets include cash, stocks, bonds, investments, credit union, savings, and checking accounts, and real estate in which one does not reside. However, for Medicaid eligibility, there are many assets that are considered exempt (non-countable). Exemptions include personal belongings, household furnishings, an automobile, irrevocable burial trusts, and one’s primary home, given the Medicaid applicant or their spouse lives in the home and the home is valued under $585,000 (in 2019). For married couples, as of 2019, the community spouse (the non-applicant spouse) can retain up to a maximum of $126,420 of the couple’s joint assets, as the chart indicates above. This, in Medicaid speak, is referred to as the Community Spouse Resource Allowance (CSRA). As with the spousal income allowance, this rule only applies to married couples with one spouse applying for nursing home Medicaid or long-term services in the home or community.
One should be aware that Florida has a Medicaid Look-Back Period, which is a period of 60 months that dates back from one’s Medicaid application date. During this time frame, Medicaid checks to ensure no assets were sold or given away under fair market value. If one is found to be in violation of the look-back period, a period of Medicaid ineligibility will ensue.
Qualifying When Over the Limits
For Florida residents, 65 and over who do not meet the eligibility requirements in the table above, there are other ways to qualify for Medicaid.
1) Medically Needy Pathway – This program is for persons who are aged and are seeking regular Medicaid. In a nutshell, one may still be eligible for Medicaid services even if they are over the income limit if they have high enough medical bills, which includes health insurance costs, such as Medicare premiums, as well as bills to cover medical services. The way the Medically Needy Program, also sometimes referred to as a “Share of Cost” Program or a “Spend-Down” Program, works is one’s “excess income,” (the individual’s income over the Medicaid eligibility limit, which is often referred to as one’s “share of cost”), is used to pay his or her medical bills. Once one has paid down his or her excess income to the Medicaid eligibility limit, Medicaid will kick in for the remainder of the month. This program, regardless of name, provides a means to “spend down” one’s extra income in order to qualify for Medicaid.
Make note, the Medically Needy Pathway does not assist one in spending down extra assets for Medicaid qualification. Said another way, if one meets the income requirements for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in “spending down” extra assets. However, one can “spend down” assets by spending excess assets on non-countable ones, such as home modifications, like the addition of wheelchair ramps or stair lifts, prepaying funeral and burial expenses, and paying off debt. As mentioned above, one cannot simply give away assets or sell them for significantly less than their value, as Florida has a 5-year Medicaid Look-Back Period that prevents applicants from doing so. If one is found in violation of the look-back period, this may result in a period of ineligibility.
2) Qualified Income Trusts (QITs) – Persons seeking long-term care in a nursing home facility or require services in a home and community based setting have the option of putting “excess” income into a QIT. With this type of trust, a sufficient amount of money must be deposited into the account each month in order to bring the individual’s income down to the Medicaid income limit. A trustee must be named who has legal control of the money in the account, which must be used only for very specific purposes. For example, paying medical bills, personal needs allowances, and Medicare premiums. QITs must be irrevocable, which means the agreement is non cancel-able. In addition, the state of Florida must be named to receive any money remaining in the trust upon the death of the Medicaid recipient.
As with the medically needy pathway, this option does not assist one in “spending down” excess assets in order to meet the Medicaid asset limit. More on QITs.
3) Medicaid Planning – the majority of persons considering Medicaid are “over-income” or “over-asset” or both, but they still cannot afford their cost of care. For persons in this situation, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible. Read more or connect with a Medicaid planner.
Specific Florida Medicaid Programs
Like many states, Florida has replaced their Medicaid HCBS Waivers with a Medicaid managed care program. Former waivers, such as the Alzheimer’s Disease Waiver, Nursing Home Diversion Waiver, Assisted Living for the Elderly (ALE) Waiver, and the Consumer Directed Care Plus (CDC+) Waiver, have all been discontinued and replaced with the Statewide Medicaid Managed Care – Long Term Care (SMMC-LTC) program. To be clear, most but not all of the services and benefits that were available under the older waiver system have been preserved with the new Medicaid managed care model.
How to Apply for Florida Medicaid
Seniors wishing to apply for Florida Medicaid can do so online via ACCESS. Persons can also contact their local ACCESS Service Center for additional information or assistance with the application process. Alternatively, persons may call the ACESS Customer Call Center at 1-866-762-2237. Learn more about how the Medicaid application process works.