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Florida's Medicaid spend-down program resets each month, requiring beneficiaries to submit new medical expenses to qualify for coverage
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The state where you reside has a significant impact on the care you receive and how much you pay as a Medicare beneficiary. This page describes resources to help you pay for Medicare coverage and Medicaid programs to help pay for long-term care, which is not generally covered by Medicare.
A Medicare Savings Program (MSP) can help Florida Medicare beneficiaries who struggle to afford the cost of Medicare coverage. The MSPs help some Floridians pay for Medicare Part B premiums, Medicare Part A and B cost-sharing, and – in some cases – Part A premiums.
Medicaid for the aged, blind, and disabled can pay for Medicare cost sharing expenses, and cover some services not covered by Original Medicare. Beneficiaries whose incomes and assets make them eligible for Medicaid can receive coverage for those additional services if they’re enrolled in Medicaid for the Aged, Blind and Disabled (ABD).
This program is called Medicaid for the Aged and Disabled (MEDS-AD) in Florida.
In Florida, Medicaid ABD covers dental services in emergencies. According to this website, Medicaid may also cover non-emergency dental benefits for some enrollees.
Medicaid ABD also covers eyeglasses (one pair of lenses every 12 months, and frames every 24 months), contact lenses, eyeglasses repairs, and will pay for prosthetic eyes.
Income eligibility: The income limit for MEDS is $961 a month if single and $1,261 a month if married.
Asset limits: The asset limit for MEDS is $5,000 if single and $6,000 if married.
If an individual’s income is over the eligibility limit for Medicaid for the aged, blind and disabled but their assets are below the resource limit, they can enroll in the Medicaid spend-down, which is also called the “Medically Needy Program.”
Florida Medicaid’s spend-down will approve an enrollee’s coverage in one month increments. Additional medical expenses have to be submitted to receive further coverage.
The Medicaid spend-down does not cover Long Term Services and Supports (LTSS).
Income limit: The income limit is $180 a month if single or $241 a month if married (as of 2018).
Asset limits: The asset limit is $5,000 if single and $6,000 if married.
Medicare beneficiaries who have Medicaid, an MSP, or Supplemental Security Income (SSI) also receive Extra Help. This federal program lowers enrollees’ drug costs under Medicare Part D. If you don’t receive this benefit automatically, you can apply for it through the Social Security Administration (SSA). The income limit is $1,615 a month for singles and $2,175 a month for couples, and the asset limit is $14,610 for individuals and $29,160 for spouses.
Medicare beneficiaries increasingly rely on long-term services and supports (LTSS) – or long-term care – which is mostly not covered by Medicare. In fact, 20 percent of Medicare beneficiaries who lived at home received some assistance with LTSS in 2015. Medicaid fills this gap in Medicare coverage for long-term care, but its complex eligibility rules can make qualifying for benefits difficult. What’s more – eligibility rules vary significantly from state to state.
Florida is known as an “income cap state,” because applicants only qualify for Medicaid long-term care benefits if their income is below the eligibility limit. Florida does not allow seniors with slightly higher incomes to pay what they can afford toward their care, and have Medicaid pay the rest. This means applicants with modest incomes just above the eligibility limit can struggle to pay for long-term care. Fortunately, these individuals can become eligible for long-term care benefits by depositing income into a Qualified Income Trust (which is described below).
Applicants seeking long-term care benefits have to undergo a level of care assessment.
Most seniors used to receive long-term care in nursing homes. Today, more Americans receive LTSS in their homes. But some enrollees’ medical or living circumstances make nursing home care a better fit.
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married (and both spouses are applying).
If only one spouse needs Medicaid nursing home care, the income limit for single applicants is used – and usually only the applicant’s income is counted.
Even though the income limit is $2,349 a month (if single), nursing home enrollees are not allowed to keep all of their income up to this limit. Instead, they have to pay all but a small portion of it toward their care, but can keep a small personal needs allowance (of $130 each month) and money to pay for health insurance premiums (such as Medicare Part B and Medigap).
Assets limits: The asset limit is $2,000 if single and $3,000 if married (and both spouses are applying). If only one spouse needs Medicaid, the other spouse can keep up to $128,640.
In Florida, the asset limit for nursing home enrollees increases – to $5,000 if single and $6,000 if married – if an applicant’s income is below $961 a month if single and $1,261 a month if married, meaning they also qualify for Medicaid ABD.
Certain assets are never counted, including many household effects, family heirlooms, certain prepaid burial arrangements, and one car.
A first home is not a disqualifying asset for applicants who have less than $595,000 in home equity.
Each state’s Medicaid program offers community-based long-term care through Medicaid. These services are provided in an enrollee’s home or an adult day care center, and are called Home and Community Based Services (HCBS). Enrollees continue living in the community, and don’t have to enter a nursing home.
Income limits: The income limit is $2,349 a month if single and $4,698 a month if married (and both spouses are applying). When only one spouse needs needs HCBS, the income limit for single applicants is used – and only the applying spouse’s income is counted.
Asset limits: The asset limit is $2,000 if single and $3,000 if married (and both spouses are applying). If only one spouse needs Medicaid, federal rules allow the other spouse to keep up to $128,640.
In Florida, the HCBS asset limit increases – to $5,000 if single and $6,000 if married – if an applicant’s income is below $961 a month if single and $1,261 a month if married, meaning they also qualify for Medicaid ABD.
Eligibility rules for Medicaid LTSS programs differ from other Medicaid benefits when only one spouse is applying. When this occurs, only the applying spouse’s income is counted. (With other Medicaid benefits, both spouses incomes are counted – regardless of who applies.)
Federal rules that protect against spousal impoverishment allow the spouses of Medicaid LTSS recipients to keep a Minimum Monthly Maintenance Needs Allowance (MMMNA) from their Medicaid spouse’s monthly income, along with resource and housing allowances. This rule is particularly helpful to nursing home enrollees, who would pay most of this income toward care if they weren’t able to transfer some of it to a spouse.
In Florida in 2020, these community spouses are allowed to keep:
Federal law requires states to restrict eligibility for Medicaid nursing home and HCBS to applicants with a home equity interest below a certain dollar amount. In 2020, states set their home equity limits based on a federal minimum home equity interest of $595,000 and a maximum of $893,000.
Florida has chosen to have the most restrictive limit on home equity – meaning that applicants for LTSS can’t have more than $595,000 in home equity.
Because long-term care is expensive, individuals can have an incentive to give away or transfer assets to others so they can become eligible for Medicaid LTSS benefits. To curb this incentive, federal law requires states to have a penalty period for Medicaid nursing home applicants who give away or transfer assets for less than their value. States can also choose to have an asset transfer penalty for HCBS. Medicaid will not pay for an enrollee’s LTSS during this penalty period.
Florida has an asset transfer penalty for nursing home care and HCBS. This penalty is based on a 5-year lookback period during which asset transfers and gifts are prohibited. The length of the penalty period is determined by dividing the value of what was given away or transferred during the lookback period by the average cost for private pay nursing home care (which is $9,485 a month in Florida in 2020).
Medicaid agencies must have estate recovery programs that try to recoup Medicaid’s payments for long-term care related benefits received starting at age 55. States have the option to also recover the cost of all Medicaid benefits. This is called estate recovery.
Florida has chosen to pursue estate recovery for all Medicaid costs received beginning at age 55.
But the state will not attempt an estate recovery if an enrollee is survived by their spouse or a child living at home (who is under 21, blind or disabled).
Congress exempted Medicare premiums and cost sharing from Medicaid estate recovery starting with benefits paid after December 31, 2009, but Medicaid may attempt to recover MSP benefits received through that date.
Free volunteer Medicare counseling is available by contacting the Florida SHINE at 1-800-963-5337. This is a State Health Insurance Assistance Program (SHIP) offered in conjunction with the State Department of Elder Affairs.
SHIPs can help beneficiaries enroll in Medicare, compare and change Medicare Advantage and Part D plans, and answer questions about state Medigap protections. They may also be able to offer referrals to local agencies for services like home care and long-term care. This website has more information about the SHINE in Florida.
Elder law attorneys can help individuals plan for Medicaid long-term care benefits. Use this National Academy of Elder Law Attorneys (NAELA) search feature beneficiaries to find an elder attorney locally.
Florida’s Long Term Care Ombudsman Program helps individuals understand their options for long-term care and advocates for individuals receiving LTSS. This program investigates complaints made about a person who is receiving LTSS.
The Ombudsman Program’s phone number is 1-888-831-0404. This website has more information about the program.
Medicaid eligibility is determined by the Department of Children and Families (DCF) in Florida. You can apply for Medicaid ABD or an MSP using this website. The DCF website also lists local partners who can help you file a Medicaid application.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare technical assistance contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare and Medicaid claims and appeals. In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including at Sachs Policy Group, where he worked with clients on Medicare and Medicaid issues.