Medicaid Waiver Long Term Care Services

A Medicaid Waiver program is one for which the state requested a waiver from the federal government, of certain Medicaid program requirements that apply in an institutional setting.  In doing so, a state can provide services to a target group in a community setting, rather than a nursing home.

Most clients would much rather receive help at home or in an assisted living if they are well enough to do so.  However, waiver programs are not funded in the same way the nursing home Medicaid program is funded.  This results in long waitlists for services.  The other funding-related issue is that Medicaid only pays a portion of the monthly shortfall in an assisted living setting, whereas the entire shortfall is paid in a nursing home setting.  The result?  There are clients that are simply too poor to participate in a waiver program and have no choice but to get care in a nursing home.  Two of Florida’s Medicaid Waiver programs are listed below:


Program of All-Inclusive Care (PACE)

  • Services are typically provided at home and in an adult day care setting.

Description:

PACE targets individuals who would otherwise qualify for Medicaid nursing home placement and provides them with an array of home and community-based services at a cost less than nursing home care.  PACE participants have both their medical and long-term care needs managed through a single provider.

In addition to services covered under Medicaid, PACE includes all services covered by Medicare.  This means all primary care is provided by PACE providers.  PACE is available in Lee, Collier, and Charlotte Counties, and services are provided by Hope Pace.

Program Eligibility:

To be eligible for PACE, an individual must:

  • be 55 years of age or older;
  • live within the defined service area of the PACE Center;
  • meet certain medical eligibility requirements;
  • able to live safely in the community; and
  • be dually eligible for Medicaid and Medicare, or Medicaid only. There is also a private pay option with PACE, however this is not regulated by the State.

The attorneys and staff at Prather & Swank, P.A. can help you determine whether PACE is an option for you.  If you have questions, contact Prather & Swank, P.A. at 239-288-4315 or fill out our online form


Statewide Medicaid Managed Care Long-term Care Program (SMMC LTC)

(formerly like services were delivered through the Long-term Care Diversion Program)

  • Services are typically provided at home or in a participating assisted living facility.

Practicing in the Medicaid arena means lots of acronyms and in this case, even the acronym is long.  The SMMC LTC program has two components; the MMA program and the LTC program.  Yep, more acronyms!  The MMA component provides services such as laboratory and imaging services, medical supplies and equipment, and hospital services.   The LTC component addresses the delivery of services related to long-term care such as home health care, medication management, and assisted living care.

Program Eligibility:

To be eligible for the SMMC LTC program, an individual must:

  • be 65 years of age or older;
  • or 18 or older and eligible for Medicaid due to disability;
  • meet certain medical eligibility requirements;
  • able to live safely in the community; and

The attorneys and staff at Prather & Swank, P.A. can help you determine whether receiving home and community-based Medicaid services is a good option for you.  If you have questions, contact Prather & Swank, P.A. at 239-288-4315 or fill out our online form.