Does Florida Medicaid Pay for Assisted Living?

Florida Medicaid is a state and federal program providing healthcare coverage to individuals and families who meet specific income and resource criteria. It ensures access to necessary medical services for those facing financial barriers. Medicaid also supports long-term care services for eligible individuals, including those residing in assisted living facilities.

Eligibility Requirements for Florida Medicaid and Assisted Living

To qualify for Florida Medicaid programs that assist with assisted living costs, individuals must meet criteria related to residency, medical need, and financial status. An applicant must be a legal Florida resident, a U.S. citizen, or a qualified non-citizen. Applicants must also be aged 65 or older, or be between 18 and 64 and designated as disabled by the Social Security Administration.

Financial eligibility involves both income and asset limits. For 2024, a single applicant’s monthly income cannot exceed $2,829. For a couple where both are applying, the combined monthly income limit is $5,658. If only one spouse is applying, rules allow the applicant spouse to allocate some income to the non-applicant spouse, known as the monthly maintenance needs allowance.

Asset limits are stringent, with a single applicant allowed to have no more than $2,000 in countable assets in 2024. Countable assets include bank accounts, investments, and other resources readily converted to cash. Certain assets are exempt, such as a primary home with an equity value up to $713,000 in 2024, one automobile, personal belongings, household furnishings, and prepaid funeral arrangements. Florida also has a five-year “look-back period” for asset transfers made for less than fair market value, which can result in a penalty period of Medicaid ineligibility.

Beyond financial criteria, applicants must demonstrate a medical necessity for assisted living care, referred to as needing a “nursing facility level of care.” This is determined through an assessment of an individual’s ability to perform Activities of Daily Living (ADLs) such as bathing, dressing, eating, and mobility, as well as Instrumental Activities of Daily Living (IADLs). The Comprehensive Assessment and Review for Long-Term Care Services (CARES) unit within the Florida Department of Elder Affairs conducts these medical evaluations.

Covered Services and Participating Assisted Living Facilities

Florida Medicaid’s primary program for long-term care services, including those in assisted living facilities, is the Statewide Medicaid Managed Care Long-Term Care (SMMC LTC) program. This program provides services to help beneficiaries remain in community settings rather than requiring nursing home placement. Services covered within an assisted living facility can include personal care assistance, medication management, supervision, and some therapeutic services. The SMMC LTC program also offers services such as adult day care, homemaker services, and home-delivered meals.

Florida Medicaid generally does not cover the cost of room and board in an assisted living facility. This means housing, utilities, and meals typically remain the resident’s responsibility.

Not all assisted living facilities participate in the Florida Medicaid SMMC LTC program. Individuals seeking Medicaid-covered assisted living services must identify facilities that are part of the Florida Medicaid LTC network. The SMMC LTC program operates through various Managed Health Care Organizations (MCOs) that contract with their own network of providers, so facility availability can vary by plan and region.

Application Process for Florida Medicaid and Waivers

The application process for Florida Medicaid begins with submitting an application to the Florida Department of Children and Families (DCF). This can be done online through the MyACCESS Florida website, by mail, fax, or in person at a local service center. Required documentation includes proof of identity, Florida residency, income, assets, and Social Security numbers for all household members.

After initial Medicaid eligibility is determined, a separate assessment is required for the long-term care waiver program that funds assisted living services. This assessment is conducted by the CARES unit, which evaluates the applicant’s functional and medical needs to determine if they meet the nursing facility level of care.

Once an applicant is eligible for the SMMC LTC program, they are required to enroll in a managed care plan. These plans deliver Medicaid long-term care services. Applicants receive information to choose a plan, and a choice counselor can assist in selecting a plan. The entire application process, from submission to approval, generally takes between 30 to 45 days, though it can be longer if additional information or a disability determination is required.

Financial Contributions and Cost Management

Even when an individual qualifies for Florida Medicaid’s SMMC LTC program, they remain responsible for certain costs associated with assisted living, such as room and board.

Individuals may also have a “patient responsibility” or “share of cost” for covered services if their income exceeds a certain personal needs allowance. This amount is the portion of their income that must be contributed towards their care costs each month. After accounting for a small personal needs allowance, most of the beneficiary’s remaining income is expected to go towards the cost of care, including room and board.

To help manage room and board costs, some individuals may explore programs like Supplemental Security Income (SSI) or the Optional State Supplementation (OSS) program. OSS is a state-funded cash assistance program for low-income seniors who reside in assisted living facilities and meet specific financial and functional requirements. In Florida, OSS payments can be made directly to the assisted living residence, which can help offset a portion of the room and board fees.