Medicaid and Long Term Care in Florida

Long-Term Care Costs and Coverage

Americans spend approximately $50 billion/year on out-of-pocket long term care expenses. Many individuals do not realize (until they need help) that Medicare is not intended to cover long term care expenses. Medicare is an acute care medical insurance, much like the plans working people get through their employer. In very general terms, Medicare’s coverage is generally limited to hospital care and skilled, rehabilitative care (in home or nursing facility, for a limited time), doctor’s care (Part B), and drug coverage (Part D).

Options for Long-Term Care

The majority of long term care and assistance is provided by families or paid for privately. Many people think of long term care as a place – the nursing home. But, today there are more options for people to get assistance in their homes or assisted living settings, and help ranges from medication management and fall detection systems to adult day care and meal delivery.

With longer life expectancies and more chronic conditions (up to 4 million Americans suffering from Alzheimer’s disease, expected to jump to greater than 9 million by 2030), individuals and their families are facing the issue of how to provide the care needed – and how to pay for it. Many people have not anticipated these costs or planned accordingly. A geriatric care manager can help families struggling with these issues to determine the best options and plan wisely. With a myriad of options, it is not simple to figure out what is available and how to access it.

Medicaid for Long-Term Care

Because of the sometimes staggering costs associated with long-term care, many individuals find they need to turn to government assistance. Medicaid is a state administered program for certain low-income individuals to provide for medical care. The federal government provides general guidelines and states set specific rules regarding eligibility and programs, and there are numerous Medicaid programs, many providing medical care for low-income families and children. However, about 20% of most state Medicaid budgets are also currently paying for long-term care for seniors and disabled individuals.

Eligibility for Medicaid in Florida

Generally, all the Medicaid programs have a financial eligibility criteria (income and assets must be below a certain level) and other criteria (i.e. level of care needed, disability, etc.). In Florida, there are several “Waiver” programs in addition to the standard nursing home (ICP) Medicaid. Some of these waivers include Home and Community Based Services, Assisted Living Waiver, and the Long Term Care Diversion program. Each has its own special criteria for eligibility, which is determined by the CARES unit within the Department of Elder Affairs. Our care managers can help clients evaluate if they might be eligible for any of these programs, or which might be most appropriate. We also work closely with elder law attorneys when help is needed for financial eligibility and can link you with appropriate resources.

Medicaid and Community-Based Care

As the states look to provide more community based services and find ways to cut costs by diverting clients from nursing homes, there are more options available. This can make figuring it all out a puzzling process. We have steered many families through this process so they get the best end result. Some of the programs, such as the Long Term Care Diversion, work like a managed care program – in that they are handled through private providers (insurance companies and other providers) and individuals must choose a provider to manage their care under a capitated monthly rate. In the Diversion program, services may be provided at home or at an ALF (those that are contracted), but it is important to understand the eligibility requirements, what amount of care will be provided, and what additional costs are to the recipient to fully evaluate if it will work for the person.

Medicaid Eligibility and Rules Changes

On February 8, 2006, President Bush signed the Deficit Reduction Act (DRA) of 2005, which contained significant changes to the Federal Medicaid rules, especially related to transfers of funds. For individuals who may have received advice prior to this, it is important to get updated advice and make sure you understand how the new guidelines may affect you. So often, people hear misinformation in the community and make major mistakes.