Medicaid

Is Medicaid a state program or a federal program?

It’s both. The federal government pays half or more of the cost. The program is administered by the State, which must agree to comply with the federal Medicaid Act and regulations. There is some leeway in how the program is operated, so the State is allowed to come up with a “plan” which is submitted for approval to the federal oversight agency, Centers for Medicare and Medicaid Services, or CMS.

What state agency administers the Florida Medicaid program?

The State agency with oversight over all Medicaid programs in Florida is the Agency for Health Care Administration (AHCA.)

What does the basic Medicaid program provide?

The basic Medicaid program is also known as “State Plan” Medicaid because it is administered according to the plan approved by CMS. State Plan Medicaid is an “entitlement” program – if you qualify for Medicaid, you are entitled to receive medically necessary services. The Medicaid Act lists mandatory services which must be offered in every state program. A State can also choose from a list of optional services to add to the plan. For example, mandatory services include hospitalization and out-patient physician care services, but Florida has also chosen to provide the optional services of institutionalization in a nursing home or intermediate care facility for the developmentally disabled.

Are different services available for children?

Yes. Under the federal Medicaid Act, states must provide children with Early and Periodic Screening, Diagnosis and Treatment (“EPSDT”) services. Treatment includes any “… necessary health care, diagnostic services, treatment and other measure [described in the Medicaid Act] to correct or ameliorate … the physical and mental illnesses and conditions, whether or not such services are covered for adults in the state’s Medicaid program.” 42 USC §1396(r)(5).

In other words, states must provide any medically necessary care required by an eligible child, regardless of whether the service is a mandatory service or an optional service that is not offered to adults.

What are my rights under Medicaid?

Medicaid services can’t be withheld or taken from you without due process of law.

If you have been:

  • Denied eligibility
  • Had your services denied, reduced or terminated
  • Requested services but the agency has failed to respond with “reasonable promptness”
  • Been transferred or discharged from a nursing home

Then you are entitled to: 

  • Timely adequate written notice
  • A pre-termination hearing
  • Opportunity to present witnesses, evidence, oral argument and cross-examination
  • An impartial decision-maker
  • A written decision

In addition, the decision of the agency must not conflict with state laws and regulations. In some cases, violation of federal laws can also create a separate cause of action.

Who is eligible for Medicaid? 

For State Plan Medicaid, there are four typical routes to eligibility:

1. SSI-related Medicaid requires that you qualify for Supplemental Security Income through the Social Security Administration. SSI has a very low income and asset limit, plus you need to be able to show that you have a disability that has lasted, or is expected to last a year, and prevents you from earning “substantial gainful employment.” If you receive SSI, you automatically qualify for Medicaid. Children, as well as adults, can qualify for SSI based on the child’s disability, but until the child turns 18 (or 22 if still in school and working toward paid employment), a portion of the parents’ income is included in making the income and asset determination.

2.  Family-related Medicaid is primarily available for children and pregnant women. There is still an income limit, but it is higher than SSI-related Medicaid and changes as the child ages.

3.  Medically Needy Medicaid is available to persons with disabilities who don’t meet the income/asset limit. It is designed to cover large medical expenses by allowing coverage for any month when medical expenses meet or exceed an amount roughly equivalent to the monthly household gross income (also known as “share of cost”). Expenses will be covered only if incurred by a Medicaid authorized provider.

4.  Institutional Care Placement (ICP) applies to individuals who require the level of care for a nursing home or, in some cases, an institutional facility for persons with disabilities. The financial eligibility criteria for ICP is not as restrictive, with higher monthly income allowed and certain protections for a spouse who remains at home. Once a person qualifies for ICP or is actually enrolled in (not just on a waiting list) a home and community-based waiver program, Medicaid will also cover other medical assistance.

How will eligibility change under the new federal law?

The Affordable Care Act was signed into law on March 23, 2010. Although the ACA initially required states to expand Medicaid eligibility to adults with household income under 138% of the Federal Poverty Level (“FPL”), the U.S. Supreme Court ruled this portion of the Act unconstitutional. Instead, states may elect to expand. Despite Florida’s high number of uninsured, the Florida Legislature has not chosen to expand Medicaid, even though for the first three years, the federal government would pay 100% of the benefits. (Even after three years, the portion of cost paid by the federal government would not drop below 90%.)

 The ACA has made changes to how financial eligibility is determined for Medicaid programs. In addition, for anyone with a household income between 100% and 400% of FPL, premium tax credits (also know as “vouchers”) are available to cover a hefty portion of health insurance premiums. Click here for information on the ACA. 

Where do I apply for Medicaid? 

State Plan Medicaid eligibility is determined by the Department of Children and Families. Click here to apply online through the ACCESS website.    You can also do a test run online for information on programs that you might qualify for. Phone and in-person applications are also available.

How do I get nursing home or hospice care? 

            Institutional Care Placement: Nursing home care is available through State Plan Medicaid.  To qualify for nursing home care, the individual must go through an assessment to determine if he or she qualifies for the level of care required for a skilled nursing facility. This is known as a “CARES” Assessment. If the level of care is met, financial eligibility must be established.

Financial eligibility requirement for ICP differs from eligibility for State Plan Medicaid. Individual gross monthly income is three times the monthly amount for Supplement Security Income, which may change each year. As of 2014, the ICP income limit is $2,163 for individuals and $4,326 for couples, and an asset limit of $2,000, with certain exclusions, like the family home. For an ICP, when one person is going into a nursing home, the community spouse is allowed to retain income and assets in excess of this amount.

            Hospice: Provides Medicaid services for terminally ill persons. Application is through a local Hospice. Financial eligibility is the same as for ICP.

Can I get help to stay at home instead of having to go into a nursing home?

That is possible. Although State Plan Medicaid offers only minimal home health care, there are limited-enrollment Medicaid programs (known as “home and community-based services” waiver programs) that do provide more extensive care for people who would otherwise be eligible for a nursing home. There is also a program known as “nursing home transition” available to people who have been residing in a nursing home for at least 60 consecutive days. Keep reading for more information.

What is a Medicaid Waiver Program?

 Under basic or State Plan Medicaid, all services must be available to all enrollees, statewide, and the enrollee must have the freedom to choose among Medicaid providers. The Medicaid Act gives states the ability to seek a “waiver” of these requirements for a variety of reasons. In Florida, waivers have been granted for pilot projects (not offered statewide), managed care options (limiting freedom of choice) and to provide special services to a special group of enrollees, like home and community-based services to persons with developmental disabilities who might otherwise be institutionalized.

What is Medicaid Managed Care? 

In 2011, the Florida Legislature passed the Medicaid Reform Act that made substantial changes to how Medicaid services will be delivered. Under the Act, most Medicaid enrollees are now required to participate in a “managed care organization” (MCO) that will provide oversight of the individual’s different health care needs. MCOs are usually either a health maintenance organization (HMO) or a provider service network (PSN). The theory of managed care is that better coordination of care will eventually result in less need for services.

How has the transition to Managed Care taken place?

The first group that transitioned to managed care were those individuals who were receiving long-term care (LTC) in nursing homes or through certain home and community-based waiver programs. This transition took place from August 1, 2013 through March 1, 2014. For an overview of LTC Managed Care, click here.

The next transition – from May 1, 2014 to August 1, 2014 – is for people receiving medical assistance (hospitalization, doctor visits, medication, etc.) through Medicaid (known as Managed Medical Assistance, or MMA). For an overview of MMA, click here.

The state has been divided into 11 regions, with a certain number of MCOs approved for both LTC and MMA in each region. Click here for updates on Medicaid Managed Care.

Which home and community-based services waivers are now part of Long Term Managed Care?

The Medicaid Reform Act consolidated some of these programs into a new Long Term Care Waiver Program that will require participants to enroll in a managed care organization. The waiver programs now incorporated into the LTC Waiver include: Aged and Disabled Adult (including CDC+), Assisted Living, Adult Day Health Care, Nursing Home Diversion, and Channeling for the Frail Elder.

Clinical eligibility for the LTC Waiver is now based primarily on whether a person over the age of 18 meets the level of care for a nursing facility and is either elderly (over 65) or disabled. An individual must receive an assessment from the CARES Unit of the Department of Elder Affairs (DOEA) to screen for the level of care and determine the least restrictive environment. (CARES stands for Comprehensive Assessment and Review for Long-Term Care Services.) 

How does the wait list for the LTC Waiver work?

Unfortunately, the waiting lists for the separate waivers were also consolidated into the LTC Waiver; this list is now administered by DOEA. Currently, there are no adopted rules explaining how priority on the LTC waiting list is determined, although a rule development process has been initiated. 

Under DOEA policy, waiting list priority is based, at least in part, on a formula used to “score” results of an assessment that reviews client needs and living situation, with a “5” as the highest score and a “1” the lowest. Even higher priority is given to individuals who are at imminent risk (within days) of institutionalization, and for referrals from Adult Protective Services for people who are at substantial risk of abuse or neglect. Anyone who has been assessed and is on the waiting list can ask for a reassessment if there is a substantial change of condition or circumstance.

Florida also has a program for nursing home transition that is separate from the LTC waiting list. If an individual has resided in a nursing home for at least 60 consecutive days and is capable of safely receiving services in the home or community, this program should allow for transition to home and community-based services regardless of the waiting list. 

What are the home and community-based services waivers that were exempted from Long Term Managed Care?

Currently, the following waiver programs still operate independently, with their own eligibility criteria, administration and waiting lists:

Developmental Disabilities Home and Community-Based Waiver Program (DD Waiver.) Under this program, which is administered through the Agency for Persons with Disabilities, persons with developmental disabilities receive services that allow them to live in the home or in small group homes rather than in an institution. For a more in-depth discussion of this program, click here.

Traumatic Brain and Spinal Cord Injury: Administered by the Department of Health, this program provides home and community-based services to individuals over the age of 18 who meet the state definition of traumatic brain injury, spinal cord injury (or both), are medically stable, and require the level of care for nursing home. Referral by medical personnel or a social worker to a central registry is required.

Adult Cystic Fibrosis:  Provides home and community-based services for individuals age 18 and over who are diagnosed with cystic fibrosis, require hospitalization but could remain at home if provided special services.

Familial Dysautonomia (FD): Administered by AHCA. To be eligible for the program, an individual must be age 3 or older, diagnosed with FD, and meet the level of care criteria for in-patient hospital care based on an assessment.

Model Waiver (Children’s Medical): This waiver allows persons aged 21 and younger who are diagnosed as having a degenerative spinocerebellar disease and who meet the hospital level of care to remain living at home and in the community. Services include model waiver case management and respite care.

Project AIDS Care (PAC):  Administered through the Department of Health for individuals who are age 65+ or disabled and who have a diagnosis of AIDS.

PACE (Program of All-inclusive Care for the Elderly):  Medical and long-term care needs are managed by a single provider who receives capitated Medicare and Medicaid payments. PACE is only available in Dade, Lee, and Pinellas Counties for persons 55 or older, who can receive a Level of Care from the appropriate State agency and be able to live safely in the community. Must be on both Medicare and Medicaid to receive services at no cost.

People who are enrolled in (or on a waiting list for) one of these programs may also be eligible for the LTC Waiver. In that case, the individual may voluntarily chose to participate in the LTC Waiver. Be aware, however, that the spot on the current waiver will be abandonned and the individual may end up on the waiting list for the LTC Waiver. This decision should not be made lightly. 

Who has to enroll in Managed Medical Assistance and who doesn’t?

As the MMA Program has rolled out in Florida, data glitches have resulted in “mandatory” enrollment letters going to people who are not required to enroll in an MMA managed care organization. Essentially, anyone enrolled in (or on a waiting list for) an exempted Medicaid Waiver Program – like people in APD’s Developmental Disabilities Waiver – are not required to enroll in MMA. They may voluntarily enroll, and may chose to dis-enroll at any time without having show “good cause.”

If I have a problem with Managed Care, how to I report it?

You can file a complaint with the Agency for Health Care Administration. Click here for a link to the AHCA Online Complaint form.

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