When You Should Apply for Medicaid

When You Should Apply for Medicaid

When it comes to applying for Medicaid, it is easy to get overwhelmed with the very strenuous application process. While Medicaid eligibility is often at the top of someone’s mind, it is also very important to discuss the point at which a person can even apply for Medicaid. Assuming the person is financially eligible, some individuals can apply right away, while others may first need to get on a waiting list.

When can someone apply for Medicaid in Florida? Before we answer that question, let’s discuss what Medicaid is and who oversees it. Medicaid is a joint program between the federal and state governments that provides health care to eligible individuals throughout the country. It is funded by both the state and federal governments and is administered by the states according to federal guidelines and requirements.

In Florida, Medicaid is managed and administered by the Agency for Health Care Administration (AHCA). While AHCA oversees Florida’s Medicaid program, it is also responsible for the regulation and licensing of Florida’s nursing homes, assisted living facilities, and other health care facilities.

Did you know there are several different Medicaid programs in Florida? Our elder law attorneys work mostly with Medicaid in the long-term care context. Florida’s long-term care Medicaid programs can assist people with paying for care in a nursing home, assisted living facility, or at home. It is available for eligible individuals who are 65 years of age or older, or individuals who are 18 or older with a disability.

When to apply for long-term care Medicaid depends entirely on which benefits a person is applying for. In other words, the right time for submitting an application, depends entirely on the level of care the individual requires.

To be more specific, the point of entry into Medicaid depends on whether the individual resides in a nursing home, an assisted living facility, or is living at home.

When it comes to long-term care, there are two primary Medicaid programs:

  • Institutional Care Program (ICP): This is Medicaid for those requiring care in a skilled nursing or rehabilitation facility. The institutional care program helps those in skilled nursing facilities pay for the cost of their care.
  • Home and Community-Based Services (HCBS): This is also known as Statewide Medicaid Managed Care, Long-Term Care program (SMMC LTC) or Medicaid Waiver/Nursing Home Diversion is for those receiving care in the community setting at either an assisted living facility or at home. This program provides assistance toward the cost of assisted living or home care.

When Can Someone Apply?

Institutional Care Program

Individuals in need of Medicaid in the skilled setting (rehabilitation or nursing home) can apply right away if they are eligible. There is no waitlist for this program – think of it as an entitlement program. If the applicant is in a skilled care facility (nursing home or rehabilitation center) as well as medically and financially qualified, then he/she is entitled to Medicaid. This is the green light: if you are eligible and in skilled care, you can apply right away. Many of our clients are relieved to learn this. Individuals must submit the application during the month they are seeking benefits to begin.

Home and Community-Based Services

The Home and Community-Based Services (Medicaid Waiver) is appropriate for individuals that require the level of care provided by an assisted living facility or those who can live at home with home health care. In Florida, AHCA has implemented the Statewide Medicaid Managed Care (SMMC) program. The SMMC LTC program is essentially the Medicaid waiver program in Florida.

There is a waitlist for this program. Individuals seeking Medicaid services at Home or in Assisted Living must get on the waiting list prior to applying. To begin the application process, individuals must contact their local Area Agency on Aging, Aging and Disability Resource Center (ADRC) and make a request for Home and Community-Based Services.

The individual or their representative will then be required to go through a telephone interview or screening assessment, which will determine placement or priority on the list. This screening will involve questions pertaining to the individual’s activities of daily living. Individuals in the frailest condition will receive the highest priority on the waitlist.

The ADRC will notify individuals when their name has come off the waiting list. Coming off the wait list means the person may apply for Medicaid. This is the green light. Once someone is notified that he/she has come off the list they can begin the Medicaid application process. The individual may apply for Medicaid if he/she is eligible. The individual must be eligible before he/she applies.

Coming off the waitlist is not the same thing as a Medicaid approval; it simply means the individual can submit their Medicaid application if they are eligible. This is very important for our clients to understand. Learning of the waitlist can be frustrating for some families, especially those who are desperately in need of services. Those families may want to consider other options, such as PACE.

Program of All-Inclusive Care for the Elderly

PACE is an additional option for Pinellas County residents. PACE, which stands for Program of All-Inclusive Care for the Elderly, is a program to consider for those who wish to remain in their home. PACE offers a combination of medical and long-term care services in the community. There is no waiting list for PACE if there is a slot available. The individual must be eligible for Medicaid and submit an application prior to being accepted.

To learn more about the process or discuss the possibility of additional options such as the PACE program for Pinellas County residents, please contact our office to schedule an appointment. We at Hill & Kinsella have experienced elder law attorneys eager to assist with answering your questions about the often-overwhelming Medicaid application process.

Reach out to us today by calling (727) 240-2350 or by completing our online contact form.

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