Florida Statewide Medicaid Managed Care

What is the Florida Statewide Medicaid Managed Care - Long Term Care Program?

Medicaid recipients who reside in a nursing facility or receiving home and community based services must participate in the Statewide Medicaid Managed Care - Long Term Care Program (SMMC-LTC).

Anyone who meets the financial level of care as determined by DCF and medical (nursing home) level of care criteria as determined by the (CARES) will be able to receive services in their nursing home of choice. So, if a long-term care plan enrollee is denied a service that is needed, the Medicaid recipient can appeal through the plan’s grievance process or through the Fair Hearing Process.

There is no waiting list for nursing facility services under the Florida Statewide Medicaid Managed Care Long-Term Care Program (SMMC-LTC). However, there is a waitlist for Home and Community Based Medicaid (sometimes referred to as the Florida Medicaid Waiver Program).

While there are no “co-pays,” those enrolled in a managed care program may have a “patient responsibility” amount for nursing facility or home and community based services. 

The SMMC-LTC plans are paid a rate depending on the region in Florida where the Medicaid-recipient is located:

• Region #10: Broward County
• Region #11: Miami-Dade
  and Monroe Counties 
  

Skilled Nursing Facilities (SNF) must contract with all LTC programs in its region – and cannot discharge a patient because of their choice of plan and must work with the patient’s desired LTC plan to arrange for payment.

Assisted Living Facilities (ALF) do not have to contract with a LTC program in its region, so the resident has to check with their plan to make sure that the ALF of their choice contracts with their SMMC-LTC program. If not, they will either need to find another program, find an ALF in their program, or dis-enroll entirely.

ALFs will only receive reimbursement for home and community-based services, not for room and board charges.

What are my Florida Medicaid Waiver long-term care plan choices?

The Statewide Medicaid Managed Care program providers can be found on the Florida Medicaid Managed Care website. Some of the Florida Statewide Medicaid Managed Care LTC Plan Choices are (as of 2020):

1. AETNA Better Health
2. Amerigroup of Florida, Inc
   
3. ‍Humana Medical Plan, Inc
4. Molina Health Plan, Inc
   
5. Prestige
6. Simply Health Care
7. Staywell
8. Sunshine State Plan Health Plan, Inc
   
9. United Healthcare of Florida, Inc.
10. Florida Community Care

Medicaid recipients will receive a welcome packet that will advise them of the SMMC-LTC plan that they will be assigned to if they do not actively choose from one of the above plans within 30 days. Medicaid recipients who want to designate a representative to assist them in the selection of a managed care plan can  sign an “authorized representative form.”

Interestingly, being enrolled in a Florida Statewide Medicaid Managed Care plan does not require foregoing their preferred Medicare Advantage or Medicare Supplement.

What Types of Services are Provided under the Medicaid Managed Long Term Care Program?

Minimum covered services that each LTC plan must provide: 

1. adult companion care
2. adult day care
3. assisted living
4. assistive care services
5. attendant nursing care
6. behavioral management
7. care coordination/case management
8. caregiver training
9. home accessibility adaptations
10. home-delivered meals
11. homemaker services
12. hospice services
13. intermittent and skilled nursing
14. medical equipment and supplies
15. medication administration
16. medication management
17. nursing facility care
18. nutritional assessment
19. personal care
20. personal emergency response system
21. respite care
22. therapies: occupational therapy, physical therapy, respiratory therapy, speech therapy
23. non-emergency transportation

For more information regarding what Florida Long-Term Care Medicaid Covers, click the link.

Expanded benefits potentially available from LTC plans:

LTC Plans also offer some combination of the following benefits (which is why it is important to compare each LTC plan):

1. ALF / AFCH Bed Hold
2. cell phone service
3. dental services (dental is an "expanded" benefit that is currently offered by all seven LTC plans)
4. emergency financial assistance
5. hearing evaluation
6. mobile personal emergency response system
7. non-medical transportation
8. OTC - over the counter medications and supplies (OTC is an "expanded" benefit currently offered by all seven LTC plans)
   
9. vision services

Waiting lists / waiting times for home and community based care are not expected to change. Priority is given to individuals based on their level of need for services.

LTC providers will provide personal care services for those who qualify, and if specified in the enrollee’s plan of care (per the case manager), including: pest control, homemaker, companion, chore, enhanced chore, and home delivered meals. Through the Participant Direction Option (PDO) the participant can sometimes choose who will provide their services (including family members or friends). Rates for PDO services are set by the LTC plans. 

What happens if the Medicaid recipient is in the community and needs skilled-nursing care?

If the Medicaid recipient in the community (home health care or ALF) is already enrolled with a LTC plan – and it is determined that the Medicaid recipient requires a higher level of care – the LTC plan will work with the nursing facility (in its network) to arrange for admission into the skilled nursing home. 

What is the role of Area Agencies on Aging (AAA)?

The local AAAs provide education about the long-term care programs (they will help Medicaid LTC recipients choose a program that fits their particular needs), screen individuals for the HCBS waiting list (and contact them when funding is available and DOEA releases them from the waiting list) and assist with the completion of medical and financial eligibility. 

Related Florida Medicaid Resources

Source Material:

AHCA Long-Term Care Frequently Asked Questions Publication

LTC (long term care) and MMA (medicaid managed medical assistance) Plan Directory.

Snapshot of Medicaid Managed Medical Assistance Program

Snapshot of Florida Medicaid Long Term Care Program

Links to Miami-Dade and Broward Area Agencies on Aging (AAA) here. 

To read more about how priority is determined when being added to the Medicaid Waiver Waitlist.

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