Navigating long-term care options can be complex, especially when it comes to understanding programs like the Statewide Medicaid Managed Care (SMMC) Long Term Care (LTC) program. This program is designed to provide essential services to individuals aged 18 and over who require long-term support to live safely and comfortably. To help clarify any confusion, we’ve compiled a list of frequently asked questions about the Statewide Medicaid Managed Care Long Term Care Program.
Understanding the Basics of Medicaid Long-Term Care
1. What exactly is Medicaid long-term care?
The Statewide Medicaid Managed Care (SMMC) Long-Term Care (LTC) program is a vital resource for eligible individuals aged 18 and older who need ongoing long-term services and support. This program operates through the collaborative efforts of three key state agencies:
- Agency for Health Care Administration (AHCA): This agency holds the federal authority over the program, sets the rules and policies, manages recipient enrollment in health plans, and conducts Medicaid Fair Hearings related to service issues.
- Department of Elder Affairs (DOEA): The DOEA is responsible for conducting screenings to assess needs, prioritizing individuals on the LTC waitlist, managing the waitlist itself, and determining medical eligibility for the LTC program.
- Department of Children and Families (DCF): The DCF focuses on determining financial eligibility for Medicaid and handles Fair Hearings related to screening results and eligibility decisions.
2. Is the long-term care program the same as “regular Medicaid”?
No, it’s important to distinguish the Statewide Medicaid Managed Care program from what’s often referred to as “regular Medicaid,” or the Medicaid state plan. The LTC program is not an entitlement program in the same way. Critically, it does not cover standard medical care, such as doctor visits or hospital stays. It is specifically designed to address long-term care needs, separate from general healthcare services.
3. What kind of services are provided under the long-term care program?
The LTC program offers a range of home and community-based services aimed at enabling individuals to remain living in their own homes or in a community setting rather than requiring institutionalization. These services are comprehensive and designed to support various needs. For a detailed list, you can refer to the Home And Community-Based Services Provided By The LTC Program [ PDF Document]. However, some key services include:
- Adult Companion Care
- Adult Day Health Care
- Assistive Care
- Assisted Living Facility Services
- Attendant Nursing Care
- Behavioral Management
- Caregiver Training
- Care Coordination/ Case Management
- Home Accessibility Adaptations
- Home Delivered Meals
- Homemaker Services
- Hospice Care
- Intermittent and Skilled Nursing
- Medical Equipment and Supplies
- Medication Administration
- Nutritional Assessment / Risk Reduction
- Nursing Facility Care
- Occupational Therapy
- Personal Care
- Personal Emergency Response System (PERS)
- Respite Care
- Physical Therapy
- Respiratory Therapy
- Speech Therapy
- Transportation to LTC Services
4. How are these long-term care services actually delivered to recipients?
Individuals enrolled in the program receive all their approved services through managed care organizations, often referred to as health plans. These organizations coordinate and oversee the delivery of care, ensuring recipients have access to the necessary services outlined in their care plan.
Eligibility and Enrollment in the LTC Program
5. Am I eligible for the Florida Medicaid long-term care program?
Determining eligibility for the Florida Medicaid long-term care program involves a screening and assessment process. The Department of Elder Affairs (DOEA) plays a central role, using screening scores to prioritize individuals for placement on a waitlist. They also manage releases from the waitlist as program capacity becomes available and conduct thorough assessments to determine medical eligibility for LTC services. Separately, the Department of Children and Families (DCF) assesses financial eligibility for Medicaid. Both medical and financial criteria must be met to qualify for the program.
6. What are the specific steps to take to receive LTC services?
The process for accessing LTC services involves a clear three-step procedure:
Step 1: Screening. The first step is to contact your local Aging and Disability Resource Center (ADRC) to initiate the screening process. This initial contact is crucial.
- During a telephone call, an ADRC representative will ask you a series of screening questions to understand your current needs and situation.
- The answers to these questions result in a screening score and priority rank, which are used to determine your placement on the waitlist, if necessary.
Step 2: Eligibility Determination. If your screening indicates a need for services and you are placed on the waitlist, you will be contacted when program enrollment slots become available.
- Staff from the DOEA’s Comprehensive Assessment and Review for Long-Term Care Services (CARES) program will conduct a comprehensive assessment to determine if you meet the medical eligibility criteria for long-term care services.
- Simultaneously, the DCF will evaluate your financial situation to determine if you meet the financial eligibility requirements for Medicaid. You will receive a notification letter by mail outlining the outcome of this financial eligibility assessment.
Step 3: Enrollment. If both medical and financial eligibility are approved, you will be officially accepted into the LTC program.
- The Agency for Health Care Administration (AHCA) will send you a welcome packet containing essential information, including guidance on choosing a managed care plan that best suits your needs.
Waitlists, Screenings, and Assessments Explained
7. What is involved in the “screening” process?
Due to the limited availability of in-home and community-based services within the LTC program, a screening process is essential to manage access. Before you can formally receive these services, you must undergo a screening. This involves speaking with a trained professional who will ask detailed questions about your health status and your needs related to daily activities. These screenings are conducted by the Department of Elder Affairs’ Aging and Disability Resource Centers (ADRCs). The screening is designed to fairly and effectively allocate resources to those with the most pressing needs.
8. How are individuals placed on the LTC waitlist?
Following the completion of your screening, your score will determine whether and where you are placed on the LTC program waitlist. Placement is directly linked to your screening score; a higher score indicates a greater need and results in a higher priority on the waitlist. Individuals with lower priority scores may not be placed on the waitlist if their assessed needs are less urgent relative to others seeking services. It’s important to understand that the waitlist ensures that those with the most critical needs are prioritized for receiving services as soon as possible.
Once you are released from the waitlist, the Department of Elder Affairs Comprehensive Assessment and Review for Long-term Care Services (CARES) program will reach out to gather more detailed information from you. This step is crucial to confirm that you meet all medical requirements necessary to receive services through the LTC program.
9. What is a CARES “assessment”?
The CARES program plays a crucial role in the Medicaid system. It is mandated to review every individual who either requests Medicaid nursing facility services or seeks home and community-based services through Medicaid waiver programs, including the LTC program. This review is termed an assessment and is carried out by CARES staff when enrollment in the LTC program becomes a possibility for an individual on the waitlist.
Assessments are conducted by a registered nurse and/or a qualified assessor. To ensure appropriate care levels are determined, each application is reviewed by a doctor or another registered nurse. The primary goal of the assessment is to thoroughly understand an individual’s long-term care needs and to recommend the most suitable care setting. Typically, CARES staff conduct these in-person assessments in the individual’s home environment, and this service is provided at no cost to the individual or their family.
10. What does “level of care” mean in the context of LTC services?
To be eligible for Medicaid LTC services, an individual must not only meet medical requirements but also be determined by the CARES assessment to require a specific “level of care.” This generally means needing a level of care equivalent to that provided in a nursing home. There is a specific exception for individuals diagnosed with cystic fibrosis, who may qualify with a hospital level of care need. The determination of the level of care is based on a comprehensive evaluation of the person’s medical condition, the therapies and treatments they require, and the services they are currently receiving at the time of the assessment.
The “level of care” can range from individuals who are currently residing in or imminently require placement in a nursing facility, to those who are at serious risk of needing nursing facility placement. Individuals at urgent risk often require consistent access to routine medical and nursing treatment and care. They may have complex health-related needs due to physical or mental illness, necessitating a level of care that Medicaid LTC services are designed to support. (Reference: s. 409.983, Florida Statutes)
Contact Information for Further Assistance
11. Who should I contact if I have general questions about LTC services?
For general inquiries regarding LTC services, you can reach out to your local Aging and Disability Resource Center (ADRC). Alternatively, you can call the statewide toll-free Elder Helpline at 1-800-96-ELDER (1-800-963-5337) for assistance and information.
12. Who can answer my questions about Medicaid eligibility specifically?
For questions specifically related to Medicaid eligibility, please contact the Department of Children and Families Public Benefits and Services. They can provide detailed information and guidance on financial eligibility requirements.
13. What should I do if I’m experiencing issues with receiving long-term care services from my health plan?
If you encounter problems receiving your long-term care services through your managed health plan, it’s important to report these issues. You can contact the Medicaid helpline at 1-877-254-1055 to report any concerns. Additionally, you have the option to file an online complaint using the Florida Medicaid Complaint Form.
Back: Make a Complaint or Ask for a Fair Hearing (about LTC Services)
Return to the LTC Home Page
