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Florida Medicaid and Long Term Care Programs

Determining what programs are available to assist individuals with long term care needs and how to pay for these programs can be daunting. It is important to understand what services the programs provide, and what the eligibility requirements are for the programs.

Every state sets its own guidelines for Medicaid eligibility and services. Medicaid services are overseen by the Agency for Health Care Administrations. Eligibility for Florida Medicaid is determined by the Department of Children and Families (DCF). In order to qualify for Medicaid services, an applicant needs to submit a Medicaid application. DCF will determine whether the applicant is eligible for Medicaid assistance.

Medicaid Requirements for Aged and Disabled

Florida administers several programs to assist individuals with long term care needs. There are different Medicaid eligibility requirements for each of these programs. The general requirements for Medicaid eligibility require an applicant to:

  • Be 65 or older or if under 65, the applicant must be disabled by Social Security criteria;
  • Be a U.S. citizen or qualified noncitizen;
  • Be a Florida resident; and
  • Meet the monthly income limit of $828 for an individual and $1,118 for an eligible couple.

Long Term Care Programs

The most commonly used programs for assistance with long-term care needs include: the Institutional Care Program (ICP), the Aged/Disabled Adult Waiver Program (ADA Waiver) and the Assisted Living for the Elderly Waiver Program (ALE Waiver).

Institutional Care Program (ICP)

The Institutional Care Program, which is more commonly referred to as the Nursing Home program, is a medical assistance program that helps qualified individuals pay for the cost of care in a nursing home. To be eligible for Medicaid assistance with this program, applicants must meet the basic Medicaid eligibility requirements and the following additional requirements:

  • Need the high level of care provided by nursing homes;
  • Monthly income limit of $2,094 for an individual and $4,188 for a couple who are both in a facility;
  • Asset limit of $2,000 for an individual and $3,000 for a couple who are both living in a facility.
  • If the individual or couple meets the Medicaid income requirements (set out above), they are entitled to a greater asset limit of $5,000 or $6,000 respectively.

Community Spouse Allowance

A spouse of an individual who is institutionalized is called a “community spouse" because he or she continues to live in the community. A community spouse may keep a monthly allowance. The community spouse’s income allowance is computed as follows:

$1,839 (minimum monthly maintenance income allowance) PLUS excess shelter costs MINUS community spouse’s monthly gross income EQUALS community spouse income allowance.

Excess shelter cost is the amount by which the community spouse’s shelter costs exceeds $552 per month. Shelter costs may include rent or mortgage payment, homeowner’s insurance, condo maintenance fees, and a standard utility allowance of $343 per month. The total community spouse income allowance cannot exceed $2,841.

Patient Responsibility

The Agency for Health Care Administration sets the rates that a nursing home can charge Medicaid patients. Once an individual meets the eligibility requirements for the Nursing Home program, Medicaid will begin to pay a portion of the nursing home bill. Medicaid does not pay the entire cost of an individual’s nursing home expenses. The individual must contribute an amount based on his monthly income. This amount is referred to as “patient responsibility." Medicaid pays the nursing home the remaining expense based on the Medicaid approved rate for the facility.

Aged/Disabled Adult Waiver Program

Another program to consider is the Aged/Disabled Adult Waiver Program (ADA Waiver). This program provides home and community-based services for individuals in need of nursing home care who could remain at home if provided special services. To be eligible for this program, applicants must:

  • Be age 18 through 64 and determined disabled or blind according to Social Security standards or be age 65 or older;
  • Need the level of care provided by a nursing home as determined by the Department of Elder Affairs, Comprehensive Assessment and Review for Long Term Care Services (CARES);
  • Meet the same income and asset limits as the Nursing Home program.

Assisted Living for the Elderly Waiver Program

Depending on the level of care needed, another program that can be useful is the Assisted Living for the Elderly Waiver Program (ALE Waiver). This program provides home and community-based services for recipients who reside in qualified Assisted Living Facilities (ALFs). To be eligible for this program, applicants must:

  • Be age 60 through 64 and determined disabled according to Social Security or be aged 65 or older;
  • Need the level of care provided by a nursing home as determined by the Department of Elder Affairs, Comprehensive Assessment and Review for Long Term Care Services (CARES); and
  • Meet the general Medicaid eligibility requirements and the income and asset limits.

As with the Nursing Home program, special policies apply when one spouse is applying for or receiving Assisted Living benefits and the other spouse is a community spouse.

How to Apply

To take advantage of Medicaid assistance and the above mentioned programs, applicants can either go to the web page at http://www.myflorida.com/accessflorida/ or contact their local Department of Children and Families ACCESS Florida Office. An additional resource to consider for more information regarding the application process and programs is the Department of Elder Affairs. The Department of Elder Affairs can be reached at 1-800-963-5337.

Applicants and individuals applying on behalf of the aged and disabled should consider working with an elder law attorney to apply for Medicaid assistance and programs. Many attorneys who practice in the field of elder law have mastered the application process and eligibility requirements. While applicants are free to apply without assistance from an attorney, working with an elder law attorney can take the stress and complexity out of the process.

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