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Medicaid in Florida: What You Need to Know

Medicaid in Florida: What You Need to Know
December 1, 2022

Healthcare is obviously expensive. When you’re disabled, though, or advancing in age, your medical costs go up significantly. How will you pay for those expensive prescriptions? What about long-term care facilities or home health care? That type of care is unaffordable for most people in Florida.

The good news is, an elder needs lawyer in Florida can help you navigate the complicated Medicaid programs and other assistance available for those in need of special health care options.

Here's what you need to know about Medicaid in Florida.

It's important to know that Medicaid is not one thing. Medicaid is not one program.

Medicaid is really an umbrella term for multiple different programs and there are three or four programs that I deal with most of my office.

The highest level of long-term care Medicaid program in Florida is called the institutional care program – or ICP. This is for Floridians who are in rehab or long-term skilled nursing facility care, commonly thought of as a nursing home.

If you know anything about nursing homes, you know that they are very, very expensive. They typically cost somewhere between $9,000 and $12,000 a month – that's a very standard range that I see in the state of Florida. For many people that will decimate their life savings.

In order to be eligible for the ICP nursing home program to get help paying for a nursing home, you have to pass an income test and an asset test. This means if your income is above a certain amount, you do not naturally qualify. If you have more than $2,000, you also don't naturally qualify.

What people do with kind of a variety of these Medicaid programs is they come to a lawyer like myself and my law firm, Elder Needs Law – we serve all of Florida. People come to us saying that we have some money and we don't want to lose it all to the nursing home. Can you get us onto Medicaid?

If they're in a nursing home, we would legally and ethically protect their assets and get the government to cover a substantial portion of their nursing home costs. Their nursing home care in a nursing home kind of the deal is once you're financially eligible – meaning your income is below a certain level or if your income exceeds a certain amount – we have what's called a qualified income trust that we can use.

Once you're financially eligible and in the program, the deal with Medicaid is that all of your income – less $130 – will go to the nursing home, that will be what's called your patient responsibility. Then, Medicaid picks up the difference. So. if you're in a $10,000 per month nursing home and your income is just for round numbers $2,130, your patient responsibility will be 2000. Medicaid will let you keep $130 for just haircuts and little odds and ends and toiletries and things like that. And then Medicaid will pay $8,000 difference. That's a pretty good deal.

Now, there are some exceptions to that if you are married. If the Medicaid recipient was married to someone who is not in a nursing home, there is a way to divert a portion of the nursing home resident’s income over to what we call the community spouse.

The idea behind this is not to force the community spouse into abject poverty because they happen to be married to someone who's in a nursing home. They also have a higher asset limit, meaning they can keep a decent amount of money in their personal name while the Medicaid recipient can only have less than $2,000.

So, that's kind of the highest level of Medicaid program that we routinely work with.

The next level down is for folks who need to either be in an assisted living facility and not a nursing home. There's a difference between those two types of care. They both provide long-term care services but the ALS – the assisted living facility – is a lower level of care that's needed.

Or, my client wants to remain at home. But in order to do so they need home health care. This means they really can't live independently, but they're not sick enough or they haven't deteriorated enough yet to where they require to be in a facility of some kind.

That program is called the Medicaid waiver program. It's also called Home and Community Based Services Medicaid and is a different Medicaid program than the one that pays for nursing home care. ICP pays for nursing home care. Medicaid waiver helps to pay for an assisted living facility or home health care. The financial criteria are the same, meaning your income has to be below a certain level and your assets have to be below a certain level. There are a few differences though.

The first is the Medicaid waiver program has a waitlist. Part of what we do a really good job at is helping you minimize the amount of time you or your loved one spend on that waitlist. Then, the benefit you get is a little bit different.

In an assisted living facility depending on where you are in the state of Florida, Medicaid will contribute typically somewhere between $1,300 and $1,500 toward the assisted living facility. If that facility accepts Medicaid, which you have to verify, it might be a little bit more, maybe it's $1,550. It might be a little bit more than $1,500, it might be a little bit more than $1,300. It's kind of different throughout the state of Florida.

But that is it. If the assisted living facility is $5,000 per month and you have $2,000 worth of income, Medicaid contributes, let's say, another $1,500, there's still a difference, right? There's still some amount due, and the assisted living facility is going to want their bill paid. Sometimes they'll negotiate a little bit but sometimes family members are contributing on top of their loved one’s income and on top of what Medicaid pays. It's important for people to be aware of that as well.

As part of the Medicaid waiver program, some people who want to stay at home still have to go through the waitlist process. Once they're on the program, Medicaid will approve them for a certain number of hours. Rarely is it ever anything approaching 24 hours a day.

Let's say Medicaid will approve 30 hours and your loved one needs 50 hours a week of home health care. You either have to privately pay for the difference or you have to go through an appeals process to take Medicaid to task and say you've undervalued the number of hours that I or my loved one needs for home health care for them to live at the home. There's a process for doing that.

So, we have Medicaid ICP nursing home Medicaid waiver, which is the program that helps to pay for ALF and some home health care. Kind of the next level down program that I work with is called QMB, and that stands for Qualified Medicare Beneficiary. The primary feature of that Medicaid plan is that it does not have a long-term care benefit, but it will pay for Medicare Part B premiums.

It will also allow you to join what's called a DSNP plan – which stands for Dually Enrolled Special Needs plan. Essentially, it is an excellent Medicare Supplement. It'll cover your co-pays. It'll cover prescription costs or you pay a very limited copay (it's typically between $1 and $10 per prescription if it's a Medicare-approved prescription).

So, QMB is a really nice plan. My clients who like to take advantage of it are either:

· Elderly or disabled folks who need long-term care but don't want to wait – they need some help with expensive prescriptions now while they're on the waitlist for the Medicaid waiver program (because there's no waitlist for QMB)

· Clients who don't have long term care needs but maybe they have cancer or they're diabetic and they have really expensive prescriptions, that is kind of a financial disaster for them. QMB can be a wonderful program to help them pay for that.

QMD has a different income and asset threshold than Medicaid Waiver and Medicaid ICP.

Finally, there's what's called MEDS-AD – Medicaid for the Aged and Disabled. That's for folks who do not have Medicare, but they are disabled and they've been deemed disabled and it's just a good health insurance plan. You get on what's called Community Medicaid and it helps with those co-pays and prescription costs. Again, it's essentially like QMB for folks who don't have Medicare or are not entitled to Medicare.

There's more than that, of course. There's Medicaid for pregnant women and women with minor children or foster kids. There’re all these different flavors of Medicaid. The only ones that I work with are the Meds-AD, QMD, Medicaid Waiver, and Medicaid ICP programs.

If you're saying to yourself, it would be nice to have this program but I have just too much by way of income or too much by way of assets, we have legal and ethical ways of protecting your income and assets and still getting you qualified for these different programs. They can be amazingly beneficial for my clients who are disabled, over the age of 65, in need of long-term care, or who have expensive medication.

This is Medicaid in a nutshell. There is certainly much more to it, but what we like to do is if there's something that is of interest to you and you're anywhere in the state of Florida, give Elder Needs Law a call and schedule a consultation. We can talk to you about your specific issues and then we will tailor a plan unique to fit your needs.

There's more than one way to do it. Typically, we have more than one strategy. They all have pros and cons and what we're doing is – depending on your specific situation or set of circumstances – we're tailoring a plan that fits your needs.

If you have any questions, please give us a call to schedule a consultation. We're here to help.


Find more helpful resources:

●     Can I keep Florida Medicaid if I temporarily have more than $2,000?

●     Dual Eligibility for Medicare and Medicaid: What it means for you

●     Medicare Home Health Care benefit explained

●     Can you get Home Health Care while also on hospice?

●     Nursing home ratings: How to find a high-quality home

Jason Neufeld is the Founder and Managing Partner of Elder Needs Law, a Florida estate planning and elder law firm he created in 2017. With more than 15 years of experience practicing law, he represents clients in a wide range of legal matters, including Medicaid planning, estate planning, elder law, probate, Medicare, and life insurance.

Jason received his Juris Doctor from the University of Miami — School of Law and is a member of the Florida Bar and the Broward County Bar Association. He has received numerous accolades for his work, including being named a Rising Star and Super Lawyer by Super Lawyers and among the Florida Legal Elite by Florida Trend in 2024.

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