The Florida Medicaid Waiver Program, where Medicaid recipients receive Medicaid long-term care services at home or in an ALF, is actually more accurately a service provided by the "Statewide Medicaid Managed Care Long-Term Care Program" (SMMC-LTC).
The home and community (ALF) based Florida medicaid programs have a wait-list and if you are interested in non-nursing home Medicaid services, you should get yourself on this wait list as soon as possible (nursing home Medicaid, in Florida, has no wait list).
Interestingly, you need not qualify for Medicaid's asset and income tests to get onto the wait list.
How to Get on the Florida Medicaid Waiver Wait List
Call your local area agency on aging (AAA). In Miami, the agency is called "Alliance for Aging" in Broward, the agency is called "Aging and Disability Resource Center of Broward County. Every county in Florida is assigned to an Area Agency on Aging (here is a list of Area Agencies on Aging in Florida). This can be done by your elder law attorney as well.
The AAA will take down some preliminary information over the phone and will let you know an approximate time for a follow up phone assessment.
Have a phone assessment. In Miami-Dade, for example, the phone assessment will take place "in a few weeks" - they do not provide an exact day and time. I suggest programming their phone number so you don't accidentally send the call to voicemail. We often advise that someone other than the eventual Medicaid Waiver applicant (if possible) answer the questions.
Placement on Medicaid Waiver Wait-List
The purpose of the phone assessment is to get a preliminary idea of the type of care one needs. This is not the time to be proud or to downplay the assistance the eventual Medicaid-applicant needs. Placement on the Medicaid waiver waitlist is not first come, first served. Rather, the more care one needs, the higher on the waitlist they will be placed.
Medicaid Waiver Wait list placement is determined during the screening by the assignment of a priority score. Our law firm spends considerable time with our clients, reviewing the actual questions that will be asked and coaching through how to answer truthfully yet in a way most advantageous to our Medicaid client.
After the phone assessment, you wait.
You may be waiting months.
You wait until your name is called off the Medicaid Waiver wait list.
Interestingly, at this point, you need not actually submit a Medicaid application, and so you need not be technically asset or income Medicaid qualified.
However, all this waiting provides an excellent opportunity to engage a Medicaid planning lawyer to provide the strategies necessary to become Medicaid qualified.
If, while waiting, one's condition deteriorates, you can request a re-assessment to move higher up on the Medicaid wait list.
After Being Called Off the Medicaid Waiver Waitlist
Once your name is called off the wait list, the eventual Medicaid applicant is assigned to a Medicaid benefits counselor, who will coordinate a CARES home visit. You'll also need to get your doctor to sign Form 3008 (valid for one year) verifying that you need long-term care services
This is also the time for you, or your Medicaid planning attorney, to submit your Medicaid Application to DCF, through their online ACCESS portal. Your AAA case worker can also assist you with the actual application.
After the Medicaid application is submitted and you are approved, you will be asked to pick a Medicaid managed care plan in your region with the help of a Choice Counselor at 877-711-3662.
Within five business days of selecting a managed care plan, a case manager from that plan will arrange a visit to review services and come up with a "Care Plan" to prevent nursing home placement for as long as possible. Anyone you choose can be present during the care-planning meeting.
Case managers often can only approve a limited amount of direct care services. If you need more services, including any “medical” services like attendant(nursing) care, ask the case manager whether or not you need a physician prescription and tell the case manager that you would like to submit your request to a higher authority at the managed care plan. Also ask for a notice of denial, if your request is not approved.
A special word about therapies: The Long-Term Care Waiver will provide physical,occupational, speech or respiratory therapies for maintenance, not just“improvement,” with authorizations for at least 6-month intervals.
Your Right to Appeal Service Denials and Reductions.
You have the right to challenge any denial, reduction or termination of services, or any failure to provide services with reasonable promptness. The first step to a challenge is to file an internal appeal with your plan. If that is denied, you can ask for a fair hearing from the Agency for Health Care Administration (AHCA)
If services are reduced or terminated, you can ask for your services to continue pending the appeal or fair hearing. However, you have to ask for this in writing within 10 days of mailing of the notice.
You also have the right to ask for your whole case file, free of charge, including the notes taken by plan staff on contact with you or your providers, and anything that the plan used to make its decision.
How to File a AHCA Complaint
Any Medicaid recipients or authorized representatives can file a complaint with AHCA about problems with a Medicaid managed care plan, including problems getting care or service authorizations, missed services, or inability to find providers. You can call 1-877-254-1055 or file an online complaint here.
Florida Medicaid Waiver / SMMC-LTC Resources
Area Agencies on Aging (Miami-Dade, Broward)
*A portion of this article was written by my colleague, Nancy E. Wright, Esq - email@example.com, who practices in Gainesville, FL on 12-15-2018 and was copied and pasted with her permission.