Medicaid in Florida offers number of specific programs to help the needy with the high costs of Medical care. In the elder law world, we are most frequently dealing with trying to access Medicaid to help pay for an elder's long-term care, whether it is in a nursing home, assisted living facility (ALF) or at home.  The programs helping pay for an elder's assisted living and home benefits are provided under a Federal "waiver" known as Home and Community Based Services (HCBS). These programs for the elderly are generally grouped together under the Statewide Medicaid Managed Care (SMMC) Long-Term Care Program. Accessing HCBS Medicaid (again, for in-home or in the assisted living facility, not the nursing home) can be very difficult for a number of reasons, particularly because the funding for these programs accepts a limited number of enrollees due to budgetary constraints.

The financial requirements for accessing Florida long-term care Medicaid are the same, whether the elder needs care in the nursing home, assisted living or is trying to stay at home. Accessing long-term care Medicaid can be dependent, however, on where the elder is located at the time of the application. If the elder is in the nursing home and is eligible financially, the elder will be accepted onto the Medicaid program. Nursing home Medicaid is an entitlement we all have if we qualify.  If the elder is in the assisted living facility or at home, there is a waitlist to access this program, regardless of the applicant's finances. The wait list can take years to get through, if ever. The list to access Medicaid is based on helping the frailest and needy first. Thus, moving the elder into assisted living and expecting Medicaid to help may not be a good option as you can never be sure when Medicaid will be able to help, regardless of the elder's income or assets.  There is, however, a "back door" to getting Medicaid benefits to help with assisted living or in-home care that is discussed below.

Medicaid Yes/Medicaid No

For clarification, Medicaid benefits for those in the nursing home (i.e., skilled nursing facility/rehab facility) is an entitlement provided by Florida and the federal government. If a Florida resident is in a nursing home/rehab, the nursing home has a Medicaid bed available, and the applicant is eligible for Medicaid financially (i.e., income and assets are below the applicable limit and an application has been made), the applicant will receive Medicaid to help pay for their long-term care when successfully applied for. The Medicaid application process can be difficult even under simple circumstances, but our government will have Medicaid help pay for the nursing home stay (which will generally exceed $350/day once rehabiliation has ended). The nursing home may have space limitations so the elder may not be able to stay at that particular facility, but Medicaid will still be helpful in almost any given context.

Medicaid does not, however, assure that an applicant will receive Medicaid benefits while he or she is home or in the assisted living facility or at home. Put simply, Florida only guarantees Medicaid for a qualifying nursing home applicant, not an applicant for assisted living or in-home care. Medicaid has a lengthy wait list for those applying for community Medicaid (i.e., assisted living or in-home) benefits under most circumstances. The wait list may take years for the the elder to get Medicaid, if ever, as the system only accepts the sickest people first based upon an orderly triage process.

"Bypassing" the Assisted Living Wait List

The best way to by-pass the wait list to get Medicaid benefits for the ALF is through the 60 day wait period when an elder is already in a nursing home. If the elder is already in the nursing home, we often take advantage of this opportunity to apply for and receive Medicaid, then transition the elder to assisted living with Medicaid's financial assistance. Once the elder receives Medicaid and has been in the nursing home 60 days, the applicant will be able to leave the nursing home and go home or to assisted living with Medicaid's financial support.  We have some good information on questions to ask when your elder enters the nursing home. Veteran's benefits may also assist the elder and the surviving spouse of a war time veteran. This process is tricky but if your elder is ever receiving rehabilitation in a skilled nursing facility, now may be the time to get Medicaid for him or her.

How Does the Wait List Work?

The HCBS wait list takes the sickest individuals first. Referrals are made to your local Aging Resource Center (find yours here), such as this one in Pinellas County, who manages the wait list. It does not hurt to try to place your elder on the wait list if they are needing more and more help as they age. The elder does not need to qualify for Medicaid financially to be on the waitlist, importantly. If the elder comes off the wait list, you would likely see a good elder law attorney if the income/assets were over the bare minimum.

If your elder is on the HCBS wait list, you would want to inform your Aging Resource Center of any change in health changes, falls, trips to the hospital, etc. Moving up the list likely means that the elder will need to be in a nursing home within the next 3 months, so a change in health may help him or her move up the wait list. A good elder law attorney can also be very helpful in moving the applicant up the wait list under as the attorney can help advocate while looking at the areas of health care priority. As in anything in life, an informed elder law attorney (like our law firm) can be invaluable.

Monetary Benefits for Assisted Living Medicaid

Medicaid for assisted living or in-home benefits has its limitations. This Medicaid program does not pay for all of the assisted living facility's cost, for instance, nor does it pay for 24/7 in-home care. In Florida, Medicaid will generally help with assisted living costs by reducing the by $1,200-$1,500/month. Medicaid does not pay for the room and board for the ALF, but only can pay for the medical portion. Practically, not every facility will apply the Medicaid subsidy the same way, so be sure to talk to the assisted living facility about what expected costs would be. If the elder has low income, for instance, the family may need to assist with assisted living costs. Our law firm could help protect assets above the bare minimum, which can happen even when the elder is already in the nursing home.

Example of Accessing HCBS (Medicaid) for Assisted Living 

Again, there are two ways to get HCBS Medicaid:

  1. When the applicant is in the nursing home for 60 days and applies for/gets Medicaid before leaving; or
  2. When the applicant gets put to the top of the Waitlist. Here, the top of the waitlist essentially means the applicant scores a 5 on the screening with Aging Resource Center.

As an example:

Mom, age 91, was living at home with advancing dementia. Mom falls and breaks a hip, going to the hospital and then to the skilled nursing facility to receive rehabilitation. While in the nursing home, the family decides that the elder is not able to go home due to safety reasons. The family hires an elder law attorney to assist with a Medicaid application. After 30 days of receiving rehabilitation, the elder's Medicare benefits stop paying for rehabilitation. With the attorney's Medicaid application in the works, the elder will stay in the nursing home (skilled nursing facility) until the Medicaid application is approved. After 60 days and Medicaid approval, the elder will be able to leave the nursing home and go to an assisted living facility with assistance from Medicaid.

This scenario is in contrast to moving Mom directly into the assisted living facility from her home. Even if Mom is financially eligible for Medicaid (i.e., her assets are below the income and asset levels) and she is in the ALF, she would only join the Medicaid wait list - so there is no assurance that Medicaid will help with her assisted living costs, even if she is out of money.

How does the Waitlist scoring system work?

Scoring for the HCBS waitlist gives a priority level of 1-7 with a seven being highest. Practically speaking, a 5 is likely to be the highest in most situations as a 6 applies only to minors and a 7 is for those at imminent risk ( where the applicant is in the community, unable to care for themselves, has no capable caregiver AND they are likely to require care in a nursing home or ALF in 1-3 months).

Questions that involve the scoring system involve the following:

  • Is there a primary caregiver?
  • Does the applicant live alone?
  • How is the caregiver's health?
  • How confident is the caregiver in their ability to continue to provide care in the future?
  • What is the applicant's overall health?
  • Does the applicant need help with their activities of daily living? (ADLs)
  • Are there financial limitations in obtaining necessary medical care?

How the applicant (or their family) answers these questions provides a point scale for the answers. Again, a 5 generally moves the applicant off the waitlist immediately, which then allows the Medicaid application with the Department of Children and Families (DCF).

If you want to do a "deep dive" on the Florida waitlist, you are welcome to read the applicable section of the Florida Administrative Code, which sets for the procedure followed by the applicable Aging Resource Center.

When the Elder Runs out of Money in Assisted Living, What Happens?

We often see that when families are shopping for assisted living facilities, the family will ask the assisted living facility (ALF) representative "what happens if mom (or dad) run out of money? Will we have to move him/her?" Here, the assisted living facility representative may tell them that mom/dad can stay in the facility on Medicaid. But we know this advice is not quite right because:

  • Even if mom/dad spend all of their money on assisted living care, this does not mean that Medicaid will be there due to the wait list that makes no guarantees on when the elder's name comes to the top; and
  • Medicaid generally provides only the estimated $1,500/month subsidy, so an expensive ALF may require more money than mom/dad's income.

Trying to pay for an elder's assisted living facility is even more difficult than trying to get care in a nursing home. Why is that? The long wait list for ALF Medicaid that will likely not correspond when/if the elder runs out of money. Here is an example, however, of what to do when the elder is in assisted living and is about to run out of money:

Mom has been in assisted living dementia care for years at the cost of $4,000/month. Her income is only $1,500/month and she is down to $30,000 in assets. At this rate, mom will be out of money in less than a year. But if the family hires an elder law attorney, mom could move to a nursing home for 60 days and the elder law attorney could protect what little money mom has left.  After mom is in the nursing home for 60 days and the Medicaid has been approved, she can leave the nursing home to go to the ALF on Medicaid with an $1,500/month subsidy for her care. Some facilities work with the family to lower the rate of payment as well, so the family would likely shop around for assisted living facilities that accept Medicaid, although most ALFs accept Medicaid.

Getting HCBS Medicaid at Home

Most of the discussion here have been about Medicaid in the assisted living facility but the State of Florida will provide help at home for an applicant. The main point of HCBS Medicaid is to keep people out of the nursing home, so benefits are provided at home. We often see, however, that unless there is a full time in-home caretaker, the benefits are not enough to stay at home, even with Medicaid providing assistance. Benefits will generally provide about 3 hours of home healthcare workers per day for about 18 hours/week, on average. We generally think about home Medicaid as help/respite for the in-home caregiver.

NOTE: Using HCBS for home care is intended as an alternative to institutionalization (i.e., the nursing home or assisted living). HCBS applicants must be verified to be at a nursing home level of care to even qualify for a HCBS Waiver, which is why getting off the waitlist is so difficult. The stated goal of the program is that "managed care plans are required to provide an array of home and community-based services that enable enrollees to live in the community and to avoid institutionalization." There is no true cap on the hours provided for in-home care except that they must be medically necessary, but that includes services that enable an enrollee "to have access to the benefits of community living, to achieve person-centered goals, and to live and work in the setting of his or her choice." The key thing to remember is that if you are trying to get in-home care, above the baseline, you will need to argue with the managed care provider under these general guidelines.

Differences between Nursing Home and HCBS Medicaid

This article reviews about the differences between the Medicaid program to pay for the nursing home v. assisted living/at home Medicaid. The differences are subtle but important, especially if you are looking to get Medicaid for assisted living benefits.

VA Benefits can also be Helpful to help with Assisted Living Costs

If your elder needs care in an assisted living facility, many often overlook VA benefits, which can provide even more money than Medicaid. We have more information VA Pension and Assisted Living benefits. It is possible to get both VA and Medicaid benefits for your elder! One aspect of getting VA Pension, which can include aid and attendance, is that part of the pension may count towards Medicaid income purposes, which means the applicant may need a qualified income trust (QIT).  Learn more about VA Pension and Florida Medicaid here. So watch out for this trap - if your elder is on Medicaid and then gets VA benefits, you may need an elder law attorney!

Is HCBS a "Waiver" Program?

Yes. When you are doing research and looking for long-term care outside the nursing home, sometimes people refer to the program as "Waiver."  This is technically accurate, although the more accurate name would be HCBS.

Hiring an Elder Law Attorney may be Vital

Even if the elder's income or assets are above the minimum (i.e. $2,000 in countable assets for a single person), an elder law attorney can assist the elder and the family in making the correct decisions. The good elder law attorneys (they are not all created equally) know the ways to access Medicaid more quickly, which will help the elder leave the nursing home faster and get to the assisted living facility. A good elder law attorney can also know ways to advocate to move the elder up the assisted living waitlist, as well. Relying upon the nursing home to do the Medicaid application is not always the best idea due to the many complexities. If the elder has income or assets above the policy limits, an elder law attorney can be vital to legally protecting assets, reducing income, and more. Our law firm, no matter where you live in Florida, can help with your application.  

Can I give Money Away for Medicaid Qualification?

No!  I had a conference where Mom/Dad were both coming off of the wait list and were finally going to be able to qualify for Medicaid. The problem was that Mom/Dad had over $70,000 in the bank - which is some $67,000 over the asset limit for a married couple. The representative from the Aging Resource Center told the family that Mom and Dad could give this money away and apply for Medicaid - but that was just plain wrong. You cannot give money away within 5 years of a Medicaid application! Here, an elder law attorney (like us) can help legally protect assets and apply for Medicaid - hiring the attorney will more than pay for itself.

Just Had a Dementia Diagnosis?

When people are looking for long-term care placement, they often are dealing with an elder's recent dementia diagnosis. We have more on the the legal steps to take upon a dementia diagnosis. We also have a free guide to Alzheimer's Care that you may want to download.

Do you Want to Move Your Loved One to Florida?

If you are thinking about moving your loved one to Florida, this webpage discussed moving for Florida for long-term care Medicaid.

Help When You Need It

If your loved one needs long-term care, please do not hesitate to contact us for assistance, even if you do not live in the Tampa Bay area!  We also offer free monthly seminars on Medicaid and asset protection planning.  You may also want to read about the 7 lies your friends will tell you about Medicaid and elder law in Florida.

Want to Talk?

We charge a $200 phone consultation fee for a one hour phone call to discuss you/your loved one's situation. We receive phone calls from across Florida (and beyond) and we are glad to help triage your case. In our conference, we would review the elder's income and assets and also review their estate planning documents in order to help make the best decision for you and your loved one.

Get our Free Book on Asset Protection Planning!

We offer a free, comprehensive guide to helping your loved one and protecting assets from the nursing home.  Download our book, Protect Your Nest Egg from a Florida Nursing Home today!

Also, we have another book available that reviews this information, and much more, in Your Guide to Florida Long-Term Care Medicaid. This book will help you and your family if you are in a long-term care crisis and need good information without all of the difficulties.

D. Rep DeLoach III
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Estate Planning and Board Certified Elder Law Attorney