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^{Senior Health>Medicaid>>How It Works>>}

HOW MEDICAID WORKS Services Covered under Florida Medicaid Inpatient hospital Outpatient hospital Physician services Transplant services Laboratory and X-ray Skilled and intermediate nursing care Home health care State mental health hospital Rural health clinic County health department clinic services Dialysis center services Transportation Ambulatory surgical centers Podiatry Dental Visual services Hearing services Community mental health services Hospice Medical supplies and equipment Nurse services Chiropractic services Medicare premiums, deductibles and coinsurance Augmentative and communication systems Medicaid is a state and federal partnership that provides health insurance coverage for those most in need. The program improves the health of seniors by paying certain medical and health care costs of those who qualify. Without Medicaid, these individuals might otherwise go without health-care services. In Florida, the Agency for Health Care Administration (AHCA) develops and carries out policies related to the Medicaid program. To determine current Medicaid financial eligibility requirements, contact the Florida Department of Children and Families (DCF). When applying for Medicaid, be prepared to provide information on your assets and income. You must also comply with other criteria. Florida, like most states, is a “spend down” state requiring that you first spend down your own assets and resources to pay for your health care (to a certain level) before you qualify for Medicaid. If you or a loved one requires 24-hour skilled nursing care and want to receive Medicaid benefits, you must have a nursing home placement eligibility assessment. You should contact the Florida Department of Elder Affairs’ Comprehensive Assessment and Review for Long-Term Care Services (CARES) office regarding this Medicaid eligibility assessment. Medicaid allows some flexibility to applicants in defining the assets that can be excluded under its non-countable assets provisions. These items are exempt and will not affect your eligibility to receive Medicaid benefits. The items are as follows: Your home (principal residence) - regardless of value. Household belongings, furnishings, personal effects and jewelry (some states limit value). A burial account of up to $2,500 (or $1,500 for SSI recipients). Burial plots for the individual or members of the family. Prepaid non-cancelable burial contracts. Cash value of life insurance policies (face value cannot exceed $2,500 or $1,500 for SSI recipients). Term life insurance policies (no face value limitation). One automobile for use by individual and family. Company pension funds, certain Keogh funds and certain trust funds. Certain income-producing property that is “essential to their self-support.” Inaccessible assets of any value. To get a better understanding of how Medicaid works and the various options available to help preserve your assets in case of a long-term illness, consult with an attorney specializing in elder law. Frequently Asked Question: “ If I have a question or complaint about a Medicaid provider, where should I go ?” You may contact the Agency for Health Care Administration (AHCA) to report a complaint or ask a question. In addition to policy development and administration, AHCA certifies Medicaid providers. If you have a complaint about your board and care at any long-term care facility, contact your local Long-Term Care Ombudsman Council (see “Resource Referral Directory”). For additional information on the Medicaid program, contact your local agency on aging, or call the Elder Helpline at 1-800-96-ELDER (1-800-963-5337).   MEDICAID WAIVER / SSI RELATED PROGRAMS Waiver Programs under Medicaid to Assist Elders Aged/disabled adult waiver Assisted living for the elderly waiver Consumer directed care waiver Nursing Home Diversion (NHD) waiver Program of All- Inclusive Care for the Elderly (PACE) During the initial roll out of Medicaid, payment for long-term care services was directed primarily to nursing home care. As caregivers and service recipients began to request that resources available for institutional care be made available for home and community-based care, the government responded with waivers and SSI programs. Today, Medicaid funds can be used to provide care in a variety of home and community-based settings. To be eligible for these programs, you must meet certain age and eligibility criteria. A brief summary of the various Medicaid Waiver and SSI related Medicaid programs are provided below:   Adult Day Health Care Waiver – Provides for attendance to an adult day health care center for residents of Palm Beach or Lee counties. This is the only service provided through this waiver. The program is best suited for clients who need supervision and or assistance during the day while a caregiver is working. Aged/Disabled Adult Waiver Program – Provides home and community-based services for individuals in need of nursing home care that can remain at home with special services. Recipients make informed choices about home and community-based services in lieu of nursing facility care. Alzheimers's Disease Waiver – Provides home and community based services to individuals residing in Miami-Dade, Broward and Pinellas counties. The clients must be residing at home with a capable caregiver and have a diagnosis of Alzheimer’s disease. The program will focus on supporting the caregiver while delaying or preventing admission to a nursing home. Assisted Living for the Elderly Waiver Program – Provides home and community-based services for recipients residing in qualified assisted living facilities (ALFs). Recipients make an informed choice of receiving home and community-based services in lieu of nursing facility care. Channeling Waiver Program – Provides home and community-based services through a contractual agreement with an organized health care delivery system. This program is only available in Dade, Monroe and Broward counties. Developmental Services Waiver Program – Provides services to individuals with developmental disabilities in order to enable them to remain at home in their communities. Hospice Medicaid Program – Helps maintain a terminally ill individual at home for as long as possible by providing in-home care and avoiding institutionalization whenever possible. However, hospice is also available to individuals residing in a nursing facility. Institutional Care Program (ICP) – Helps people in nursing facilities pay for the cost of their care. Unlike Medicare, Medicaid will pay for custodial care for an unlimited period of time. Long-Term Care Community Diversion Project - A comprehensive Medicaid waiver program designed to allow individuals to remain at home or in the community. Participating organizations employ case managers to coordinate medical and long-term care services. The organizations also have flexibility allowing them to provide an enriched set of services including preventative health training, home health care, durable medical equipment, dental, prescription drugs, Medicare co-insurance and deductibles, pharmaceutical counseling, arranging and coordinating medical care, family training and comprehensive supportive assistive living services in residential facilities. Medicaid for the Aged and Disabled (MEDS-AD) – Provides full Medicaid benefits to aged and disabled individuals who have incomes less than 88 percent of the federal poverty level and meet the asset limit. Note: Medicaid does not cover blind individuals, unless they have been declared disabled. Medically Needy Program – Provides Medicaid for persons with high medical bills, whose income is too high to qualify for traditional Medicaid programs. Individuals qualify for the Medically Needy program on a month-to-month basis by contributing a monthly share of cost. Optional State Supplementation (OSS) - A cash assistance program. Its purpose is to supplement a person’s income to help pay for costs in an assisted living facility, mental health residential treatment facility and adult family care home. This is not a Medicaid program and eligibility requirements for OSS may differ from Medicaid. The payment is made directly to the client and is based on the client’s income and the current OSS cost of care in the facility. Program of All-Inclusive Care for the Elderly (PACE) – PACE is similar to the Long-Term Care Community Diversion Project in that it targets individuals who would otherwise qualify for Medicaid nursing-home placement and provides them with a comprehensive service package that permits them to continue living at home while receiving services, rather than being placed in a nursing home. PACE is unique, however, in several respects. It includes both Medicare and Medicaid services and features comprehensive social services that can be provided at an adult day health center, home and/or inpatient facilities. A team of doctors, nurses and other health professionals assess participant needs, develop care plans and deliver all services that are integrated into a complete health-care plan. Project AIDS Care Waiver Program - Provides home and community-based services to individuals diagnosed with AIDS. Recipient makes an informed choice between hospital or nursing facility care and home and community-based services. Qualified Medicare Beneficiary (QMB) – Pays the Medicare monthly premiums, deductibles and co-insurance within prescribed limits for people who meet the asset limit and whose income does not exceed 100 percent of the federal poverty level. Qualifying Individuals I (QI 1) – Pays the Medicare Part B monthly premium for people who meet the asset requirements and have a gross monthly income of more than 120 percent, but less than 135 percent, of the federal poverty level. This program is limited by availability of capped federal-funding allocated to the state. Specified Low-Income Medicare Beneficiary (SLMB) – Pays the Medicare Part B monthly premium for people who meet the asset requirements and have gross monthly incomes above 100 percent, but less than 120 percent, of the federal poverty level.