What is Medicaid?

This information is compliments of the Area Agency on Aging Pasco-Pinellas  www.aaapp.org

Understanding Medicaid Programs

Medicaid is a federal program administered by each state that provides assistance to low-income individuals who meet the eligibility criteria set by that state. In Florida eligibility is based on age or disability according to Social Security Standards and on income and asset limits. Financial eligibility changes and varies by program. Apply on the internet at http://www.myflorida.com/accessflorida/.

Full Medicaid benefits provide a variety of health services, but they must be obtained from providers who are certified to accept payment from Medicaid. Individuals who have Medicare may also have Medicaid, but Medicaid will only pay for services after Medicare has paid. For prescription drug coverage, individuals with Medicare must enroll in the Medicare Part D Prescription Drug Plan.

Programs that provide full Medicaid benefits include:

Supplemental Security Income (SSI) recipients– SSI is administered by the Social Security Administration and provides financial assistance to persons age 65 and over and to blind and disabled persons. Individuals who receive SSI through Social Security are automatically eligible to receive Medicaid in Florida. SSI eligibility requirement as of July, 2013: Individual gross monthly income of $710 and asset limit is $2,000. Couple gross monthly income of $1,066 and asset limit is $3,000.

MEDS for Aged and Disabled (MEDS-AD)– This program serves a limited group of those age 65+ or disabled who meet income and asset criteria and do not have Medicare A or B. It also serves clients who are in other Medicaid programs. Eligibility requirement as of July, 2013: Individual gross monthly income of $843 and asset limit of $5,000. Couple gross monthly income of $1,138 and asset limit of $6,000.

Institutional Care Program (ICP)– ICP helps people age 65+ or disabled and in nursing facilities pay for cost of their care plus provides general medical coverage. Must meet level-of-care as determined by the Department of Elder Affairs CARES Unit. There may be financial responsibility for the patient and eligibility may involve an Income Trust. Financial eligibility requirement as of  July, 2013: Individual gross monthly income of $2,130 and asset limit = $2,000. Couple gross monthly income of $4,260 and asset limit = $3,000 if both persons are being deemed eligible.  For ICP, when one person is going into a nursing home, then the community spouse is allowed to retain resources in excess of these amounts.

Aged Disabled Adult Waiver Program (ADA Waiver)**- Provides home and community-based services for individuals 60 years of age or older or disabled persons age 18 – 59 who are in need of nursing home care who could remain at home if provided special services. These individuals must meet ICP financial criteria and must meet a level-of-care as determined by the Department of Elder Affairs CARES Unit. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Assisted Living for the Elderly Program (ALE Waiver)**– Provides home and community-based services for individuals aged 65+ or aged 60+ and disabled who reside in qualified Assisted Living Facilities (ALF). Must meet ICP financial criteria and must meet a level-of-care as determined by the Department of Elder Affairs CARES Unit. This program does not pay the room and board costs of ALF care. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Long Term Care Diversion Program Waiver Program**– A program for individuals age 65 and over who need nursing home care and meet financial and functional requirements. Services are provided through a managed care provider (HMO). If the individual chooses the managed care option, the HMO will manage the individual?s medical needs regardless of their living situation?home, ALF, or nursing home. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

PACE**- PACE (Program of All-inclusive Care for the Elderly) uses Medicare and Medicaid funding to offer a comprehensive array of services including medical care, dental/vision, pharmacy, transportation, and homecare services. For individuals who qualify financially, these services are provided at no cost. All health care services, including primary care and specialist services must be received from the PACE provider or an entity authorized by the PACE provider. PACE is only available in Dade, Lee, and Pinellas Counties for persons 55 or older, who receive a Level of Care from the appropriate State agency and are able to live safely in the community. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Hospice Program– Provides Medicaid services for terminally ill persons. Apply through a local Hospice. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Developmental Services Waiver Program (DS Waiver)** and Family Supported Living Waiver**- Prevents institutionalization by allowing individuals age 3 and over with developmental disabilities to remain at home in the community. Financial eligibility is the same at the Institutional Care Program (ICP). See above. Contact the Agency for Persons with Disabilities for information.

Project AIDS Care Waiver Program (PAC Waiver)** and Cystic Fibrosis Waiver Program (CF Waiver)** offer support to individuals with a diagnosis of Aids or CF. The PAC Waiver is for persons age 65+, or determined disabled according to Social Security Administration standards. CF Waiver is for persons age 18+. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

** Funding for these programs is limited. Not everyone who meets the financial and medical criteria will be able to participate in the program.

Medicaid Programs that have limited Medicaid benefits include:

Medically Needy– Provides Medicaid for persons with high medical bills but who are not eligible for Medicaid because their income or assets are too high. Those enrolled in this program must incur a certain amount of medical bills each month, which is known as “share of cost”. This amount is based on income and household size. Once the share of cost is reached, the DCF can approve full Medicaid benefits for the remainder of that month only. Medicaid does not cover the costs of prescription drugs for Medicare recipients who must now use the Medicare Part D prescription coverage.

Qualified Medicare Beneficiary (QMB)– Individuals who qualify for QMB are eligible to have Medicaid pay for Medicare Premiums for Parts A and B, Medicare deductibles, and Medicare coinsurance within the prescribed limits. This is the only Medicaid benefit. Eligibility requirement as of July, 2013: Individual gross monthly income of $958 and asset limit of $7,080*. Couple gross monthly income of $1,293 and asset limit of $10,620*.

Special Low Income Medicare Beneficiary (SLMB)– Individuals who are eligible for SLMB are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. This is the only Medicaid benefit. Eligibility requirement as of July, 2013: Individual gross monthly income of $1,149 and asset limit = $7,080*. Couple gross monthly income of $1,551 and asset limit of  $10,620*.

Qualified Individuals (QI-1)– Individuals who are eligible for QI1are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. The income limits are higher than SLMB and payment is only guaranteed through the end of the year the application was made. This is the only Medicaid benefit. Eligibility requirement as of July, 2013: Individual gross monthly income of $1,293 and asset limit = $7,080*. Couple gross monthly income of $1,7453 and asset limit = $10,620*.

All full Medicaid recipients and QMB, SLMB and QI-1 beneficiaries are automatically entitled to Extra Help/Low Income Subsidy (LIS), with Medicare Prescription Drug Plan costs. It pays all or most of the annual deductible, provides coverage during the gap period, and pays the monthly premium up to a base amount. Co-pays are the responsibility of the individual. Without Medicaid the LIS eligibility requirement as of 2013: Individual gross monthly income of $1,437 and asset limit of $11800*. Couple gross monthly income of $1,939 and asset limit of $23,580*.

A $20 general income disregard is granted for these programs
* Individuals may have additional assets up to a set limit that are identified for burial expenses.

Medicaid has complex programs. The eligibility requirements mentioned above are meant to provide basic information only and do not include detailed information that should be obtained through DCF. The Fact Sheet is for information purposes and is not a legally binding document.

Source: July, 2013 “SSI-Related Programs-Financial Eligibility Standards” compiled by the Florida Department of Children and Families (DCF).