Medicaid Waiver Home and Community Based Services

I want to thank my colleague Nancy E. Wright, Esq. (newright.law@gmail.com) for giving me permission to publish excerpts from this well-written article she wrote on December 15, 2018.

Florida has brought together under one umbrella an assortment of Medicaid programs that provide long-term services and supports in the home to adults who need a high level of care. These programs, known as Medicaid Waivers, are now part of the Statewide Medicaid Managed Care Long-Term Care Program (which also covers nursing home care). For simplicity’s sake, we will call the part of the Program that provides home services the “Long-Term Care Waiver.” 

The Long-Term Care Waiver, like all Medicaid programs, involves both the state and federal governments. Florida's Agency for Health Care Administration (AHCA) provides oversight and is ultimately responsible for the Waiver's compliance with federal and state laws. To administer the Waiver, AHCA contracts with various managed care plans around that state to act as the gatekeepers for the services and supplies that the Waiver covers.

Long-Term Care Medicaid Waiver Eligibility in Florida

The Long-Term Care Waiver is for adults who are:

  • Either age 65 or older, or over 18 and have a disability, and
  • Need a nursing home level of care 

The individual must also be financially eligible, under the same criteria used for Medicaid nursing home eligibility. In 2019, an individual’s monthly income may not exceed $2,313 and the non-exempt resource limit is $2,000. As these rules are complex, discussing financial Medicaid requirements with an attorney experienced in Medicaid planning is encouraged.

Long-Term Care Waiver Covered Services

The goal of the Long-Term Care Waiver is to “provide an array of home and community-based services that enables enrollees to live in the community and to avoid institutionalization."

Every Medicaid managed care plan must offer at least the following services:

•Adult Companion
•Adult Day Care (Adult Day Health Care)
•Assistive Care Services
•Assisted Living Facility Services
•Attendant (Nursing) Care
•Behavior Management
•Caregiver Training
•Case Management
•Home Accessibility Adaptation
•Home Delivered Meals
•Homemaker
•Hospice
•Intermittent and Skilled Nursing      

•Medical Equipment & Supplies
•Medication Administration
•Medication Management
•Nursing Facility Care
•Nutritional Assessment and Risk Reduction
•Occupational Therapy
•Personal Care
•Personal Emergency Response System
•Physical Therapy
•Respiratory Therapy
•Respite Care
•Speech Therapy
•Transportation  

Click here to see the Long-Term Care Waiver Coverage Policy. This link shows, not only the required benefits that the managed care providers must provide to Florida Medicaid Long Term Care program participants, but also shows some of the extra (non-mandatory) benefits that some providers give as an incentive to choose one plan over another.

Medicaid waiver enrollees will work with a CHOICE counselor to choose a long-term care plan that best meets their needs and then has 90 days to switch to another plan offered in the same region. Afterwards, there is an open enrollment period once year in which long term care waiver plans may be changed.

Services maybe delivered through managed care-contracted providers (most choose this option) or through a Participant Directed Option (PDO) allowing you to hire, train, supervise (if necessary fire) your own service providers, including friends or family (within limits), if the Medicaid Waiver enrollee lives at home.

The Medicaid Waiver Participant Directed Option

To utilize the Participant Directed Option (PDO), you want the following services to be listed in your care plan: adult companion care, attendant care, homemaker, intermittent and skilled nursing (if the one to be hired is a licensed RN or LPN), and personal care (depending on what your needs - for adult companion, homemaker or personal care services medical certifications or licenses are not needed.

The participant hires a "direct service worker" who is paid by the Medicaid Long Term Care Managed Care Plan based on that plan's set rate. The participant will receive a Medicaid PDO hiring packet including tax forms, background report requests, legal agreements, required training, etc..

Medicaid Waiver Long Term Care Enrollees who express interest in PDO will go through a screening where they will verify that they have the ability to direct their own care and employ their own workers (and interview, train, supervise, plan for emergencies, complete time sheets, fill out employment tax forms, develop emergency back-up plans, fire the employee (or have a representative available to be responsible to handle these employer-type activities on behalf of hte Medicaid Waiver recipient, for no compensation).

Because of the substantial responsibilities involved with PDO, most Medicaid long-term care waiver participants stick with a managed care provider (Humana, AETNA, Sunshine Health, etc...) to provide care servcies.

Click here for more information on the Participant Directed Option or more here: PDO.

However, getting on a Florida Medicaid Long Term Care Waiver Plan is not automatic. Those who seek benefits to be received at home or in an assisted living facility, will need to go through a screening process and be placed on a waiver wait list.

To learn more about the Medicaid Waiver Wait-list and application process, click on the link.

     

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