Your Florida Medicaid Information Guide A Basic Primer on Florida Medicaid: What it is and How to Obtain it LISA KLINE GOLDSTEIN, ESQ. LKG LAW, P.A. 561-267-2207 WWW.LKGLAWPA.COM 2012 [Type text] Page 21
Chapter 5: The Long-Term Care Community Diversion Waiver Program (a/k/a The Diversion Program) Now that you are familiar with the requirements for Medicaid eligibility we can discuss the two types of programs that pertain to most applicants. The first program we will discuss deals with Home Health Care (HHC) and Assisted Living while the other program focuses on Nursing Home placement. Home and Community-Based Service Waiver Programs are the federally approved Medicaid programs authorized by the Social Security Act to provide services in the home for persons who would otherwise require institutional care in a hospital, nursing facility, or intermediate care. The Long Term Care Community Diversion program (Diversion Program), administered by the Department of Elder Affairs, differs from Florida s other community-based care waiver programs in that it covers both medical and long-term care services. Program providers are paid a capitated rate (Meaning per head rate) to cover all needed services, including Medicare co-payments, premiums, and deductibles. Since it is far more costly to pay for nursing home care than to pay for services needed to keep participants in the community, providers have a financial incentive to ensure that participants receive the services they need to avoid expensive nursing home placement for as long as possible. Individuals that meet the following criteria are eligible to receive services under the Diversion Program: Be 65 years of age or older Reside in a Diversion Project service area Be a Florida resident Be a U.S. citizen or qualified noncitizen 22
File for any other benefits to which they may be entitled (including Veteran s Improved Pension) Disclose any rights to third party liability (i.e., health insurance) Have Medicare part A and part B Meet facility level of care criteria and additional clinical criteria as determined by the Department of Elder Affairs' CARES Unit Meet the income limit of $2094/month for an individual Meet the asset limit of $2000 for an individual or $3000 for an eligible couple (exclusions apply for community spouse) In addition to the above, the applicant must: Require some help or supervision with 5 activities of daily living (ADL) such as bathing, dressing, walking, toileting, eating, transferring OR require some help with 4 ADL plus require supervision of medications OR require some help with 3 ADL and have a diagnosis of Alzheimer's Disease OR require total help with 2 ADL OR have a diagnosis of a degenerative or chronic condition requiring daily nursing services. Diversion waiver services include a choice of at least two providers for: adult day care, assisted living, chores, consumable medical supplies, environmental accessibility and adaptation, escort, family training, financial assessment and risk reduction, home delivered meals, homemaker, nutritional assessment and risk reduction, personal care, personal emergency response systems, respite care, occupational, physical and speech therapies, home health and nursing facility services. Managed care organizations and other qualified providers here in Palm Beach County and the Treasure Coast (such as Amerigroup, American Eldercare, Tango-Citrus, Universal, Evercare, Vista) enter into a contract with the State and receive a capitated payment to provide, manage and coordinate a qualified enrollee's full continuum of care. 23
Generally speaking, the managed care organizations provide care through contracted providers, which can include home health agencies and assisted living facilities. The providers then contract with each individual assisted living facility and negotiate a rate whereby the facility agrees to provide the elder with the needed services. This rate is different depending on the provider and the room and board rate established by the facility. This amount covers all services and is deducted from the total room rate. If the difference is more than the resident s income the facility has the right to ask the resident to pay the difference- but only for the room- not for services. The providers (Amerigroup, Tango-Citrus, American Eldercare, etc.) each have a menu of additional services they can choose to provide for a reduced cost to the individual. As a resident you have the right to talk to all providers to determine which provider best suits your needs. Keep in mind that each assisted living facility chooses who they wish to contract with for Diversion services. Some facilities work with only one provider, some work with all of them. Unlike Medicaid at the nursing home level, Diversion pays a lump sum amount towards health related services and does not offer full coverage of cost at an Assisted Living Facility (full coverage includes health care services and room/board). The program may pay $800 to one facility and $1200 to another. This amount covers all health care related services and is deducted from the total room rate. If the difference is more than the resident s income the facility has the right to ask the resident to pay the difference- but only for the room and board portion of the monthly charges. The negotiated rate between the facility and the managed care organizations are for a semi-private (shared) room. If you are interested in a private room, you must inquire about the cost of a private room which, in most facilities, is higher than that of a shared one. Here is an example of how the Diversion Program works: John Smith has a monthly GROSS income of $1200 from social security and $1400 from a pension. Assisted Living Facility A has a total room rate cost of $3500.00 a month, $500 of that amount is what Medicaid considers to be the care portion. Therefore every month John Smith will need to pay out of pocket $3000.00 to the 24
facility. However, his income is only $2600.00 dollars and since he cannot have more than $2,000 in assets in order to be Medicaid eligible, someone other than John (a spouse, child, or friend) must supplement the additional expense in order for John to reside at that particular facility If John does not have the resources available to cover his share of the cost he is out of luck and will need to find an Assisted living facility that fits into his budget. In addition, should the cost of the facilities room rate increase John Smith is responsible for that increase. There is no monetary offset given by Medicaid Diversion to you if you reside in your own home. A monetary offset is given only if you are receiving care in an assisted living facility However, there are services offered to you in your own home by Medicaid Diversion Program such as providing you with a home health aide (caregiver) to assist you with activities of daily living, for up to several hours per day as well as providing certain medical supplies and social work services. There is a very long waiting list for the diversion program. If you are not on the list, you must call the CARES department to register. Believe it or not, there is no public record of the number of people on the WAITLIST or where a particular individual may be on that list. The applications are processed in Tallahassee for the whole state of Florida. The placement on the list is supposedly influenced by the level of care that the person in need requires. Currently there is no legislatively mandated monitoring system in place to enforce the Waitlist system. Some of our clients have been on the waitlist nearly two (2) years before they were offered services through Medicaid. So sign up as soon as possible! Once your name is selected from the WAITLIST for available services and an application has been filed, benefits will begin the month in which DCF approves your application. While there are retroactive benefits available if the applicant is in a Nursing home (ICP Program), in the case of the Diversion Program, there are no retroactive benefits allowable. approved for the applicant. Approval (and hence eligibility) is as of the month Medicaid is 25