The “Long-Term Care Program” has two parts: a home and community-based “Waiver” program for individuals who qualify for a nursing home but choose home care, and Medicaid nursing home care. This discussion only relates to the home care, or “Waiver” portion of the LTC Program.
What is the LTC Waiver Program?
Like other Medicaid home and community-based service programs, the purpose of the LTC Waiver is “to provide an array of home and community-based services that enable enrollees to live in the community and avoid institutionalization.” These programs are intended to shift the balance from care in institutional settings to care in less restrictive settings, like the home or an assisted living facility.
Unlike State Plan Medicaid, enrollment in the LTC Waiver is capped. This means that there is a waiting list for enrollment.
Who is clinically eligible for the LTC Waiver?
The Medicaid Reform Act initially consolidated five existing home and community-based waiver programs into a single program to be operated by private managed care organizations (MCOs). Recently, the LTC Waiver added three more waiver programs into its fold: Traumatic Brain and Spinal Cord Injury, Adult Cystic Fibrosis, and Project AIDS Care. All of these separate programs had very specific criteria for enrollment, but the LTC Waiver clinical criteria is much more general:
- Age 18 or over
- Disabled or elderly (over age 65)
- Meets the level of care required for a nursing facility
What is the financial eligibility criteria for the LTC Waiver?
Financial eligibility is through Institutional Care Placement Medicaid.
What services are provided through the LTC Waiver?
All LTC managed care organizations are required to offer a standard set of services, both medical and supportive, to allow individuals to safely remain in their homes. Services are coordinated through a case manager who is employed by the managed care organization. The case manager should assist the enrollee in determining what array of services are needed and provide ongoing coordination of services and advocacy on behalf of the enrollee. Service descriptions are set out in the LTC Program Coverage Policy.
Supportive services include:
Companion Care, Adult Day Care, Assisted Living Supports, Behavioral Management, Caregiver Training, Home Accessibility Adaptation, Home Delivered Meals, Homemaker Services, Medication Administration and Management, Nutritional Assessment, Personal Emergency Response System and Respite Care.
Mixed services (which are also offered through State Plan Medicaid, but in restricted amounts), include:
Assistive Care in Adult Family Care homes, Attendant Nursing Care, Intermittent Skilled Nursing visits, Medical Equipment and Supplies, Personal Care, Occupational Therapy, Physical Therapy, Respiratory Therapy, Speech Therapy, and Transportation.
How do I get assessed for the LTC Waiver?
Generally, you will need to be screened to determine your priority score for the waiting list. To set up a screening, call the Aging and Disability Resource Center for the region where the applicant lives. The screening is typically done over the phone, but the applicant can ask to have another person present to help with the call.
How does the LTC Waiver waiting list work?
Prioritization for the LTC Waiver waiting list is now set out in statute and rule. Under the statute, the Department of Elder Affairs is required to to maintain the statewide wait list through a system that prioritizes individuals “using a frailty-based screening tool that results in a priority score.” However, there are three categories of individuals that are given priority enrollment without having to complete a screening:
- Aged 18, 19, or 20 years with a complex medical condition requiring 24-hour-per-day medical, nursing, or health supervision or intervention.
- A nursing home resident who requests to transition into the community and who has resided in a Florida-licensed skilled nursing facility for at least 60 consecutive days.
- Determined by Adult Protective Services to be at high risk and placed in an assisted living facility temporarily funded by the Department of Children and Families.
For all other applicants, screening results in a priority scale of 1 (not in need) to 5 (highest need). In addition, the rule sets out three higher categories:
- Rank 6 for individuals “aging out” of certain state-funded home care programs.
- Rank 7 for applicants at “imminent risk” of being institutionalized. This is defined as individuals are are unable to perform self-care, there is no “capable caregiver,” and placement in a nursing home is likely within a month or very likely within 3 months.
- Rank 8 is for Adult Protective Service high risk referrals.
What happens when an applicant has a high priority score and is “released” from the waiting list?
When an applicant is “released” from the waiting list, there are still several steps before eligibility and enrollment are assured:
- DCF must be provided with financial information and documentation to establish financial eligibility.
- Clinical eligibility must be documented through a face-to-face assessment by DOEA to establish that a nursing home level of care is met, and that a physician agrees that home and community-based services are appropriate. This is called a “CARES” assessment.
How does enrollment work?
When approved for enrollment, AHCA notifies the individual and provides information for selection of a managed care organization. Florida was divided into 11 regions, with each region represented by at least two managed care organizations. Click here to see which MCOs are in your region.
Once an MCO is selected, a case manager will contact the enrollee and set up a face-to-face visit to go over the program, explain services, and assess for care needs and personal goals. Under the LTC Program Coverage Policy, the MCO must also document the availability, willingness, and ability of any voluntary caregivers, as well as the amount of time that the enrollee can safely be left alone. An MCO should not deny a service because a caregiver is at work or has physical or mental limitations that restrict their ability to care.
How are MCO decisions challenged?
Enrollees whose services are denied, reduced, terminated, suspended, or not provided in a “timely manner” have the right to challenge the decision. The MCO is required to provide written notice, including not only the rule that supports the decision, but the individualized reasons for the decision. The enrollee has the right to request, free of charge, copies of all documents and records that are relevant to the decision.
Under new federal regulations, the enrollee must first appeal to the MCO before a fair hearing can be requested. This internal appeal can be expedited if necessary for health reasons. If the MCO decision is not favorable, that decision may be challenged in a fair hearing at AHCA’s Office of Appeal Hearings.
How do I report complaints against my managed care organization?
You can file a complaint by calling AHCA at 1-877-254-1055 (TDD 1-866-467-4970) or by filing an online complaint.