Difference Between Florida Medicaid Long Term Care Programs

It’s important for my (potential) Medicaid-Planning clients to understand that “Medicaid” is an umbrella term used for multiple programs. In a long-term care context, there are three primary Medicaid programs that Elder Needs Law, PLLC works with in Florida: ICP, Medicaid Waiver, or QMB for senior citizens age 65 or older, or disabled: The Medicaid Institutional Care Program (ICP) and the Medicaid Waiver Program (also known as Home and Community Based Services or SMMC-LTC). QMB is short for: Qualified Medicare Beneficiary, which I will discuss below:

This article will discuss the differences between these three Medicaid long-term care programs.

Medicaid Institutional Care Program | Medicaid ICP

The ICP long-term care Medicaid program is for those who require skilled-nursing / rehab / nursing home level of care only.

There is no wait-list for this program and approval will be granted in the same month the ICP applicant is financially qualified, medically qualified, AND submits a Medicaid application.

Once approved, the Medicaid recipient will pay their “patient responsibility” or “patient share of cost” (essentially all of their income, only keeping $160.00 per month for incidentals) and Medicaid will pay the entire difference for a semi-private room in a nursing home (which can be many thousands of dollars per month). All nursing homes must accept Medicaid in Florida, so this program can assist with the very best nursing homes in Florida.

If the Medicaid recipient is married to a non-Medicaid recipient (known as the Community Spouse), the Community Spouse may be entitled to a portion of the Medicaid recipient’s income as part of Medicaid’s anti-spousal impoverishment policy. This is referred to as the Minimum Monthly Maintenance Needs Allowance (or MMMNA).

Medicaid Waiver | Home &Community Based Services | SMMC-LTC

Statewide Medicaid Managed Care Long Term Care (SMMC-LTC) / Florida Medicaid Waiver / Home & Community Based Medicaid are all different names for the same Florida Medicaid program.

This long-term care Medicaid program is for those who only require Assisted Living Facility (ALF) level of care OR are able to reside at home and would benefit from some home-health care.

There is a wait-list for this program. The Medicaid Waiver wait-list gives priority to those who need services the most. But the wait-list can be quite long.

Part of our service, if hired to do so, is coaching you on ethical ways to obtain a higher priority score to minimize time on the Medicaid waiver wait-list.

Once approved, the Medicaid recipient keeps 100% of their income.

If in an ALF: Medicaid contributes approximately $1,400 - $1,900 per month (could be slightly more or less, depending on amount of care needed, the Medicaid plan chosen, and the part of the State) toward their ALF bill.

If at home: Medicaid will pay for approximately 15-40 hours of home health care (directly to a Medicaid-approved agency) depending on amount of care that is needed. More home health care hours may be approved after an appeal.

Cash and Health Insurance Benefits with Medicaid Long-Term Care Programs

Some other tangential benefits that are included in these Medicaid programs

(primarily benefiting those who apply for Medicaid Waiver):

1.      More cash available to the Medicaid recipient. Medicaid will pay the Medicare Part B premium cost (currently automatically deducted from social security income). In 2024, that will usually result in the Medicaid beneficiary usually receiving an extra $174.00 per month in their bank account.

2.      More cash available to the Medicaid recipient because Medicaid will pay for most co-pays, deductibles, and prescription costs.  

3.      Potentially more cash available to the Medicaid recipient when they choose their Medicaid-Managed Plan (Florida Medicaid has contracted with marquee names such as AETNA, United, Sunshine Health, Humana, etc…). Once enrolled in one of these Medicaid plans, the Medicaid recipient has the ability to discontinue paying for their Medicare Advantage or Medicare Supplement (they also have the ability to keep their current Medicare plan if they so choose).

QMB - Qualified Medicare Beneficiary Medicaid

For those who are in need of home health care or assistance paying for an ALF (i.e. interested in the Florida Medicaid Waiver program), we often will apply for both the Waiver along with the QMB. The reason is that the Medicaid Waiver program has a waitlist and the QMB program does not. So we can get our medicaid-planning clients approved for QMB usually within 45 days so they can immediately start receiving assistance with co-pays, co-insurance, deductibles, extra cash, as well as being able to pay approximately zero to $12.00 for all Medicare-approved prescription medications.

QMB has different eligibility criteria than ICP or Medicaid Waiver.

QMB also entitles the Medicaid recipient in Florida to enroll in a D-SNP Medicare Advantage Plan (Dual Eligible Special Needs Plan). DSNP Plans offer more comprehensive health coverage and additional cash benefits for those living at home or in an ALF.

This summary is just a brief overview of what we will discuss during our consultation. The bulk of the consultation will discuss legal and ethical methods of qualifying you or your loved one for one of these Medicaid long-term care programs in a way that does not trigger the five-year look back period so you can obtain the services needed with as little delay as possible.   

Schedule a consultation today! We serve the entire state of Florida.

Elder Care Lawyer Resources

Difference Between Medicare and Medicaid

Video: Differences between Medicare and Medicaid in Florida

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