What Happens After Florida Medicaid Waiver Approval? Your Next Steps
Getting the approval notice for Florida Medicaid long-term care brings a wave of relief for most families. After the paperwork, the waiting, and the worry, it feels like the finish line.
It isn't quite the finish line, though. Approval is the start of the next phase, and what you do in the weeks right after it can shape the care your loved one receives. Here is what to expect and how to prepare.
First, a Quick Reminder: Medicaid Is Not One Program
Medicaid is a collection of programs, and this article covers only one of them. It is the Florida Medicaid program that helps pay for home health care (care in the home) and assisted living facility (ALF) care. You will often hear it called the Home and Community-Based Services (HCBS) Medicaid program, or simply the Medicaid waiver.
Approval Does Not Mean Care Starts Tomorrow
One of the biggest misconceptions we hear is that approval means home care, assisted living services, or other long-term care will begin right away. In reality, there are more steps to complete first. The good news is that benefits usually begin in the month right after approval with the State of Florida.
Step 1: Enrollment in a Managed Care Plan
After the Department of Children and Families approves the application, your loved one will be enrolled in a Florida Statewide Medicaid Managed Care long-term care plan. We'll call it a managed care plan from here on. The plans include well-known names such as Sunshine Health, Florida Community Cares, Simply Health, Humana, Molina, and United, along with a few others.
Florida Medicaid will most likely assign a plan automatically. You should receive information about the enrollment, including the name of the plan and the effective date of coverage.
You Can Switch Plans
If the assigned plan doesn't fit your needs, you have the right to choose a different one. You can start right away. Create an account on the Florida Statewide Medicaid Managed Care website, www.flmedicaidmanagedcare.com. You can compare the plans side by side there and pick a different one if you prefer.
Your Medicaid card should arrive in the mail as well. Keep it somewhere safe, because you will need it throughout the process.
Step 2: Meet Your Care Manager
Once enrollment is effective, the managed care plan will assign a care manager (sometimes called a care coordinator). This person will be your main point of contact, and your family's. The care manager gets to know the individual's living situation, care needs, and support system, and then helps coordinate the services that fit those needs.
Step 3: The Care Plan
The care plan may be the most important part of the whole process. Your care manager is responsible for developing it.
Many families assume Medicaid entitles them to a set number of home care hours. That is not how the program works. The services approved, and the amount of home care authorized, depend on the individual's assessed needs.
The care manager will visit the home and complete an assessment. Based on the person's circumstances and home situation, the managed care plan will then decide which services it considers medically necessary and appropriate.
How to Be Proactive
Because the assessment drives the care plan, preparation pays off. Here is what we recommend once you receive the enrollment information:
- Confirm the name of the long-term care plan.
- Verify the effective date of coverage.
- Contact the plan and ask when a care manager will be assigned.
- Before you talk with the care manager, put together a detailed list of the daily care needs.
What to Put on Your List
Think about the help your loved one needs with:
- Bathing and dressing
- Toileting and transferring
- Eating and meal preparation
- Medication management
- Mobility
- Supervision, including anything that is dangerous to do alone
These are known as activities of daily living and instrumental activities of daily living.
When you talk with the care manager, describe what everyday life looks like. A medical diagnosis tells only part of the story. The care manager also needs to know how those conditions affect your loved one's ability to function safely and independently, with or without help, day to day.
Think About Providers and Agencies Early
It also helps to identify preferred medical providers early. If your loved one wants to receive care at home, think about which home care agencies you would like to use. Keep in mind that you are limited to agencies that have a contract with the managed care plan your loved one is enrolled in.
Want a Friend or Family Member as the Caregiver?
If you hope to have a friend, family member, or another person of your choosing provide the home care, now is the time to tell the care manager that you want to enroll in the Participant Directed Option (PDO). We cover it in more detail in a separate video.
Ask About Other Benefits
Home care is only part of what a plan may offer. Ask your care manager about other benefits, such as:
- Delivered meals
- Home safety modifications
- Training for family members
The plan should give you a booklet listing all of its benefits. Go through it with your care manager and ask questions.
Don't Assume Caregivers Can Start Billing Right Away
Approval alone does not mean a caregiver can start getting paid or billing Medicaid. That generally can't happen until enrollment is effective, care coordination has taken place, and the care plan has been authorized through the managed care plan.
Special Considerations for Assisted Living Facility Residents
If your loved one lives in an ALF, or may need to move into one, there are a few more things to keep in mind.
Once enrollment is active, the managed care plan will begin coordinating long-term care services using information gathered during the eligibility process, including the CARES assessment through the Florida Department of Elder Affairs.
What Medicaid Covers in an ALF
In an assisted living facility, Medicaid covers only the level-of-care portion of the bill, not the room and board (rent) portion. Nursing homes are covered by a different program, so don't mix the two up.
The care manager will typically work with the resident, family members, authorized representatives, the power of attorney, and the facility's staff to decide which services are appropriate.
Check That the ALF Is in Your Plan's Network
Families often overlook this step. Verify that the assisted living facility participates in the managed care plan's provider network. If it doesn't, you may face complications that call for extra planning and coordination. If you have to switch to a different plan, you will also have to meet a new care manager and go through a new assessment, which causes further delay.
The simplest fix is to ask the facility up front: "Which managed care plan do you prefer?" Facilities hold contracts with different plans, and one plan may pay the facility more than another. The facility may not have a contract at all with the plan your loved one was first assigned to.
The Key Takeaway
Medicaid waiver approval is a major milestone and a reason to feel good. It is not the finish line. The period right after approval is when important decisions get made about services, care coordination, medical providers, and the support your loved one will receive.
Stay involved. Talk with the managed care plan, and make sure the care manager knows what your loved one's days are really like. That is how you get the most from the plan's benefits and make sure your loved one gets the help they need.
Not Sure Your Loved One Qualifies?
If you're wondering whether you can even qualify for Medicaid, you are not alone. Before we apply for Medicaid, we confirm that our clients are eligible. If income or assets are too high, we have legal and ethical ways of dealing with that.
Talk With Our Florida Medicaid Planning Team
Whether you are about to apply or are already enrolled, we are glad to help. If you are anywhere in the state of Florida and have questions about the Medicaid waiver, the Medicaid ICP process, or anything else related to Medicaid planning, give us a call.
For more information, visit our websites:
- elderneedslaw.com
- https://medicaidplanninglawyer.com/
Want a deeper look at how Medicaid can help with long-term care costs? Check out our book, Medicaid Can Pay Some of Your Long-Term Expenses:
https://www.amazon.com/Medicaid-some-your-long-term-expenses/dp/1513634712
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