Florida Medicaid long-term care at home: SMMC LTC, wait list and PDO

Florida pays for long-term care at home through the Statewide Medicaid Managed Care Long-term Care program, called SMMC LTC. You usually need to get through a wait list run by the Department of Elder Affairs first. A Participant Direction Option lets some enrollees choose and manage their own workers.

How care at home is paid for here

SMMC LTC combines nursing facility care and home and community based services (HCBS) inside managed care plans. The Agency for Health Care Administration (AHCA) is the state Medicaid agency, according to Medicaid.gov. The Department of Elder Affairs (DOEA) runs the CARES program, which decides whether a person needs nursing facility level of care, and runs the wait list for HCBS.

Florida law lists who is eligible. Under Florida Statutes 409.979, the person must be 65 or older, or 18 or older and eligible for Medicaid by reason of a disability, and must be determined by the CARES program to require nursing facility care, or hospital level of care for someone diagnosed with cystic fibrosis.

DOEA's training slides say nursing facility services under SMMC LTC are an entitlement, but HCBS are not. The state can provide HCBS only to a set number of eligible people, based on available funding. CARES must also find that the person can be served safely in the community.

What the plans must cover

Florida Statutes 409.98 requires long-term care plans to cover at least: nursing facility care, services in assisted living facilities, hospice, adult day care, medical equipment and supplies, personal care, home accessibility adaptation, behavior management, home-delivered meals, case management, therapies (occupational, speech, respiratory and physical), intermittent and skilled nursing, medication administration and management, nutritional assessment and risk reduction, caregiver training, respite care, transportation and a personal emergency response system. DOEA's program page also lists adult companion, assistive care services, attendant care and homemaker. Services are provided based on medical necessity or because they are necessary to delay or prevent nursing facility placement.

The wait list

Florida Statutes 409.979 says DOEA maintains a statewide wait list for enrollment in HCBS through the program. Aging resource center staff certified by DOEA do the screening. A frailty-based tool produces a priority score, and people are released from the list in score order. When scores are equal, the person with the oldest date on the list goes first. The law says people with a low priority score are told about community resources and can ask for a new assessment if their situation changes.

Some people skip the screening and wait list if they meet other requirements. The statute names three groups: people 18 to 20 with a chronic debilitating disease or condition that makes them dependent on 24-hour medical, nursing or health supervision; nursing facility residents who ask to move to the community and have lived in a Florida-licensed skilled nursing facility for at least 60 consecutive days; and people referred as high risk by the Department of Children and Families under the Adult Protective Services Act who are placed in an assisted living facility temporarily funded by the Department.

Participant Direction Option

DOEA's slides describe the Participant Direction Option (PDO) as an option the long-term care plan provides to participants who have one of these services on their care plan: adult companion care, attendant care, homemaker, intermittent and skilled nursing, or personal care. It lets participants choose who provides services and how and when. Participants must live in their own home or a family home, and they are responsible for recruiting, interviewing, training and hiring their direct service workers, writing a job description, scheduling hours, and telling their case manager when they want to end a worker or leave PDO.

The pages we could read do not say which relatives may be hired. See paid family caregiver in Florida.

How to apply

1. Call for a screening. DOEA says you contact your local Aging and Disability Resource Center, and that the Elder Helpline at 1-800-96-ELDER can help you find it.
2. Apply for Medicaid. DOEA's slides say the Department of Children and Families decides financial eligibility, and that people must apply for the specific Medicaid for HCBS unless they receive SSI. The slides name the item on the application as "Medical assistance for individual in HCBS/Waiver".
3. Get a CARES assessment once you are released from the wait list.
4. Choose a plan. DOEA points to the state's Medicaid managed care choice counseling site for the plans in each region.

Older waivers no longer exist

DOEA's slides list Florida's legacy waivers that ended after SMMC LTC began, including the Assisted Living Waiver, the Aged and Disabled Adult Waiver, Consumer-Directed Care Plus, the Channeling Services for Frail Elders Waiver, the Nursing Home Diversion Waiver and the Traumatic Brain Injury Waiver. Pages that still describe these are out of date.

Questions to ask when you call

• Have I been screened for the wait list, and what is my priority score?
• Do I fall into one of the priority enrollment groups?
• Has the Department of Children and Families received my application for Medicaid for home and community based services, or am I covered through SSI?
• Which long-term care plans serve my region, and which providers do they use?
• Does my plan run the Participant Direction Option, and who can I hire?

Terms you will see

• SMMC LTC: Statewide Medicaid Managed Care Long-term Care, Florida's managed care program for long-term services.
• CARES: the Comprehensive Assessment and Review for Long-Term Care Services program, which decides whether you need a nursing facility level of care.
• ADRC: Aging and Disability Resource Center, where wait list screening happens.
• HCBS: home and community based services, the services you receive outside a nursing facility.
• PDO: the Participant Direction Option.

What this page does not cover

AHCA's own program pages were not available to our fetch tools when we wrote this, so we have relied on Florida law and DOEA. We have not described the Medicaid program for people with intellectual and developmental disabilities. See intellectual and developmental disability services in Florida for providers.

Where Carevo fits

Carevo is a connection platform and directory. We do not run SMMC LTC, screen for the wait list or decide eligibility. The care-type links below show providers that serve your area.

Find providers in Florida

• Home care in Florida
• Home health care in Florida
• Nursing homes in Florida
• Intellectual and developmental disability services in Florida
• Paid family caregiver in Florida