The federal and Florida state governments offer a program for persons with disabilities and elders, paying for the assisted living facility and nursing home care that Medicare does not cover. However, it comes with conditions. To qualify for the benefits, you should have an income limit of $2,382 and an asset cap of $2,000. You can find yourself overwhelmed and confused, necessitating professional guidance and help to understand how the program works fully. The legal team at Arnold Law has a proven track record of guiding clients and their families to ensure their legal and financial decisions are made under Florida laws. We can guide you throughout the process and give you peace of mind knowing that you will meet your medical needs.
A Brief Overview of Medicaid Planning
With the vast number of adults in the U.S. turning 65 years, it is more important than ever to plan for long-term medical costs. Medicaid was introduced as a “need-based” program administered by Florida. It pays the cost of long-term medical expenses if the older adult meets strict qualification requirements.
Essentially, Medicaid was designed for low-income individuals and those who cannot afford their long-term care help. However, the program does not provide funds to any person who applies. All applicants are individually assessed. Discussed below are the qualifications.
Residency and Citizenship
You should be a resident of Florida and a United States citizen or with proper immigration status.
You should be disabled or at least 65 years. You must meet specific medical requirements consistent with the degree of care requested. You should require care for at least thirty consecutive days.
As of January 1, 2021, the income limit for any individual applying for Medicaid benefits in Florida is $2,382. However, the law allows married couples to maintain some percentage of their income without being used against them. There is no limit for the “well spouse.”
To be eligible for Florida Medicaid planning, you cannot have more than two thousand dollars in countable assets. However, some assets can be exempted from the eligibility rule, including:
- Personal assets like your primary home (It does not apply if you are single and do not intend to return to your homestead)
- Prepaid funeral arrangements for you and your family, a maximum of $2,500 each or in any amount of an irrevocable plan
- A car with a limited value
- If you plan to stay home and have home-based nursing care, your home equity is deemed a non-countable asset.
- The applicant or their “well spouse” own life insurance up to $2,500 each
Please note that there is no “one-size-fits-all” rule when determining countable and uncountable assets. Medicaid considers the applicants and circumstances before deciding. You cannot have a considerable income or a lot of funds in the bank and qualify for Medicaid planning.
Various Medicaid Planning Programs
Medicaid is an umbrella legal term for several programs. There are three programs as far as long-term care is concerned, namely:
Institutional Care Program (ICP)
ICP is also known as the Nursing Home Care Program. It was created to offer various medical and health services to U.S. citizens of all ages. The program is jointly funded by the state and federal governments and administered by the Florida Department of Children and Families (DCF).
Typically, Medicaid-certified nursing homes provide three types of services, including:
- Required rehabilitation after an illness, disability, or injury
- Long-term health-related care and services unavailable in your community but often required due to a physical or mental condition
- Skilled nursing or medical care and services
To qualify for ICP Medicaid, you should require an intermediate or skilled degree of care in a nursing home, as the Comprehensive Assessment and Review for Long-Term Care Services program (CARES) determines. The CARES team will conduct one-on-one interviews with the applicant to gather information on the individual’s medical history and evaluate how the applicant performs their activities of daily living like:
Based on the team’s assessment and your signed physician form certifying that you require a nursing home degree of care, the team will issue the degree of care determination.
ICP does not have a waitlist and is approved after you submit your application and are medically and financially qualified.
For a Florida resident, patient responsibility is equivalent to their total gross income, not exceeding $130 for personal expenses less allowable insurance premium deductions. For a married couple, determining patient responsibility is more complicated. If a ‘’community spouse’’ or ‘’well spouse’’ has a modest income and expenses customarily shared, they can receive part of their spouse’s income to maintain reasonable living standards.
Medicaid Waiver for Home and Community-Based Services (SMMC-LTC)
The long-term care program is ideal for individuals who can reside in their homes and benefit from home-based health care or require Assisted Living Facility degree of care.
The program has a waitlist that prioritizes people who require service the most. However, the wait list could be lengthy. Luckily, a skilled Medicaid planning attorney can coach you on the proper methods to acquire a high priority score to reduce the duration on your waitlist.
Once you are called off the waitlist and submit your Medicaid application, Medicaid waiver service can start on the initial day of the following month. After your waiver benefits approval, you can keep 100% of your income.
If in an assisted living facility, Medicaid contributes about $1,400. Please note that the program does not cover room and board expenses in the ALF.
If at your home, the program will pay between $15 to $ 40 for home-based health care. It depends on your required level of care.
Every Medicaid Waiver provider should offer the following service in adherence to the Statewide Medicaid Managed Care Long Term Program Coverage Policy as stipulated by the Agency of Healthcare Administration (AHCA):
- Adult Day Care
- Assistive care
- Attendant nursing care
- Adult Companion
- Behavior management
- Case management
- Caregiver training
- Emergency care
- Hearing services
- Eye care
- Lab work
- Medication administration
- Physical therapy
- Speech therapy
- Renal dialysis
Cash and Health Insurance Benefits Related to Medicaid Long-Term Care Programs
Other benefits included in the Medicaid programs (essentially benefiting people who applied for the Medicaid Waiver) include:
- The program will cater to Medicare Part B premium costs. That results in many beneficiaries obtaining an additional $144.60 monthly.
- Since the program pays for most deductibles and copays, the recipient receives more cash.
- More cash is available to you when you choose your Medicaid-Managed Plan. After enrolling in a Medicaid plan, you can stop paying for your Medicare Supplement or Medicare Advantage.
Additionally, Medicaid Long-Term Care pays for incontinence supplies, medical equipment, occupational therapy, speech therapy, dental services, chiropractic services, respiratory services, and home accessibility adaptations.
Qualified Medicare Beneficiary (QMB) and Medicaid for the Aged or Disabled (MEDS-AD)
The program is ideal for individuals interested in ALF or home care who are on the waitlist or require help paying prescriptions and medical bills.
The program has different asset/income requirements from the Medicaid programs described above. Additionally, it does not have a waitlist and pays for premiums, deductibles, and copays.
Typically, QMB is paid alongside long-term care waiver benefits. That means recipients can receive financial help while awaiting their ALF or home-care benefits.
Florida Medicaid “Look Back Period” and Penalties
Medicaid is a “need-based” program that helps individuals who qualify for strict asset and income levels and those who have not given away property within five (5) years of their Medicaid benefit application. The rule is called the Medicaid “look-back” period. This rule does not allow you to transfer your property away to be below the legal limit.
If you transferred money within this five-year window, the state would calculate your transfer penalty based on the amount transferred unless the child is:
- below 21, or
- is blind or disabled and below 65.
The rationale of the penalty is that the amount transferred ought to have been used to cater to the senior citizen, so the DCF will analyze a period penalty that offers Medicaid disqualification. The Medicaid ineligibility duration is calculated by dividing the total amount given by the monthly private pay (nursing home facility rate) during the application. The current Florida transfer penalty divisor is $9,703 per month.
Here is an example of determining the Medicaid penalty:
A father makes a transfer of $250,000 in February 2020 to their children as an inheritance. Twenty months later, the father suffers from a stroke. He is taken to an assisted living facility a year later and makes a Medicaid application. His countable assets are below two thousand dollars, and his income is below $2,382. Due to the transfer amount in the “look-back” period, a penalty is determined as $250,000/9,703 = 25.76 months. In other words, due to the transfer, the individual will not receive Medicaid benefits for 25.76 months from February 2022.
In the example above, if the applicant’s children return the money to their father, he will not face the penalty. Their father will have $250,000 but be ineligible for Medicaid benefits because he is over the legal asset cap. With an experienced Medicaid planning attorney, the individual can lawfully protect their property even though he is in an ALF. The penalty period starts when the applicant qualifies and has applied for the program.
It is worth noting that there are no exemptions for small gifts. That means birthday and Christmas gifts are transfers as far as Medicaid is concerned and should be revealed on the Medicaid application.
Moreover, the federal annual gift tax exclusion, set at sixteen thousand dollars in 2022, does not apply to Florida Medicaid. The annual gift tax exclusion is the amount you can give away without filing your gift tax return or paying gift taxes. Only if a person transfers money throughout their lifetime exemption will their gift taxes be due.
How Does Medicare Differ from Medicaid
Medicaid and Medicare are U.S. government-sponsored programs designed to cover healthcare expenses for specific citizens. Funded by taxpayers and established in 1965, these programs have similar-sounding names, which can trigger confusion about how they work and the coverage they offer.
Medicare offers medical coverage for people at least 65 and those with a disability. Its qualifications have nothing to do with your income level. On the other hand, Medicaid is tailored for individuals with limited income. Typically, it is the last resort for people without access to other resources.
If a spouse is on Medicare and qualifies for Medicaid, the facility should accept both, and the individual may not move. While the facility can make more money through Medicare or private pay, it should accept Medicaid if it is medically necessary.
Transfers between partners do not result in a penalty period for Medicaid purposes. Nevertheless, the total marital estate is considered in a Medicaid application. Therefore, while transferring all marital property to the “well spouse” does not lead to a penalty, the couple will deal with overage by applying it to an exempt asset like a car or home.
What to Do If My Medicaid Application is Rejected?
If a person applies for Medicaid benefits and the state agency denies the application, they can appeal their denial. The agency can deny an application due to many reasons, including:
- Filing an incomplete application or wrong documents
- Failing to respond timely
- After applying, if Medicaid has questions, the agency will require answers within ten days from the date they sent the letter.
- The income is above the cap limit
- The applicant has a lot of assets
- The applicant’s physician has not correctly completed, signed, and dated the application
After rejecting your application, the agency should issue a denial notice within:
- Ninety days from your application date, if you applied for Medicaid benefits based on disabilities
- Forty-five days from your application date if you applied for the benefits on other bases
The notice should include statements indicating that:
- You are entitled to a hearing to appeal your denial
- You have a right to self-representation or hiring a lawyer
- How to request your hearing
Additionally, the notice should outline why the agency denied the application and its methodology for making the decision.
Finally, the appeal notice should outline the appeal deadline. You should request the appeal within your deadline or be needed to validate your late appeal.
Do not toss your denial notice. Instead, read it and hold on to it until the appeal is complete.
Appealing Your Medicaid Denial
First, read the notice carefully and learn Florida’s Medicaid planning rules.
Then, file your written notice and submit the request in person at the local Medicaid agency office. Ensure it is stamped to prove you submitted it before the deadline.
After the appeal date is scheduled, you should attend the hearing. Otherwise, the appeal will be dismissed. If the appeal is dismissed because you did not attend your hearing, you should show “good cause” to have your hearing reopened. You cannot use misplacing your notice or forgetting the date as justifiable reasons for missing your hearing.
The Medicaid agency should send you details about how the hearings are conducted. It should be scheduled at a realistic place, date, and time following adequate notice. At least one hearing officer (judge) can conduct the hearing as long as they were indirectly involved in previously denying your benefits and are impartial.
Preparing for Your Hearing
Before your hearing, the federal Medicaid laws allow you to view your files and review documents and records that the Medicaid agency used to deny your benefits.
You can note down all the points you want to make before the judge(s) so you do not forget them. You can also bring witnesses to testify on your behalf and question the agency’s witnesses.
If anything arises during your hearing that you believe can be settled if you submit proof to the judge(s), request that they give you more time to obtain the details before making the decision.
The judges could request another medical examination if the Medicaid agency denied your application because it believed you were not disabled. If the judges request it, you should undergo your medical examination or risk losing the appeal. The state should pay for all medical tests and exams it orders.
What Happens After Hearing
The appealing applicant will receive a written notice of the judge’s decision. If they lose the hearing, their notice will advise them on the appeal process.
If you prevail in the hearing and become eligible for the benefits, the state Medicaid agency will apply for the coverage retroactively when you qualify. Typically, it is the date you filed your application. Ensure you keep copies of the medical bills you incurred from your application date.
Debunking Medicaid Planning Myths and Misconceptions
Any seasoned Arnold Medicaid planning attorney will tell you that clients frequently come with questions and misconceptions based on what their loved ones have told them. Most Florida Medicaid planning misconceptions can be ingrained and challenging to rectify, resulting in stress for applicants and families. The section below clears up common myths.
The State Medicaid Agency Will Take Your Home
Your Florida homestead is exempt from Medicaid asset calculations if your child or spouse resides there. The home care and equity discussions apply if you are single. However, the home can be considered exempt even when you are single if you can return to it.
If You Sell Your Home After Your Partner is on Medicaid, the Agency will Take Half of the Proceeds
If the “well spouse” (married to a sick person eligible for Medicaid benefits) sells their marital home, it will not negatively affect their spouse’s Medicaid. You, the “well spouse,” could make financial decisions concerning half of your estate, which will not impact your partner’s Medicaid.
Nevertheless, your financial choices can affect your Medicaid qualification because of the Florida look-back period after the asset transfer.
The Partner’s Assets and Spending Down their Estate
You can transfer all of your assets to your “well spouse,” allowing you, the ill spouse, to qualify for Medicaid. Nonetheless, under Medicaid rules, your spouse can only keep some of the non-exempt marital assets (approximately $116,000). The best way to handle this fact is to apply the “well spouse’s” coverage of property to protect your estate’s total value.
Transferring Assets to a Partner and the Spousal Refusal of Support
Notwithstanding the above point, one spouse can refuse to cater to their partner’s medical care in Florida. In other words, the “ill spouse” can transfer their property to their “well spouse.” Then the sick spouse can apply for Medicaid benefits, and their spouse can file documents refusing to foot the ill spouse’s medical costs.
The strategy involves specific timelines and filing and requires skilled legal assistance. There are numerous pitfalls you should recognize. For example, you cannot make a spousal transfer after your “well spouse” brings notice of refusal.
Medicaid Planning and Personal Services Contracts
Creating long-term Medicaid eligibility revolves around reducing assets to two thousand dollars per person and $140,000 per couple. In creating Medicaid, you cannot give funds away since it can result in a transfer penalty. A personal service contract is one legal method to create qualifications while protecting your assets.
A personal service contract is an agreement between the elder and a caregiver (who can be a relative) to offer them personal care services for their lifetime. It is a lump sum asset transfer to the caregiver for the contractual promise of care. The state Medicaid agency cannot disqualify you for benefits if the transaction is legally binding and for fair market value; it is not a gift but a payment for services.
Some of the services the caregiver provides include:
- Consulting with medical experts
- Bill payments
- Hospital advocacy
Generally, these are the services that the ALF or nursing home does not offer. The caregiver receives payment for helping the elderly receive better care than they would obtain without an advocate in the facility.
Find an Experienced and Knowledgeable Medicaid Planning Attorney Near Me
Since nursing home costs are rapidly rising faster than your ability to pay out of pocket as a senior, Medicaid planning helps you pay for your long-term medical care without spending your life savings and selling assets. Nonetheless, there are specific eligibility requirements you should meet. Florida Medicaid planning laws are also complicated and constantly changing, making skilled legal assistance essential. At Arnold Law, we understand these qualifications and rules about meeting stringent criteria. We can assist you in reducing stress about your future care and help you determine your options based on the current situation. Please contact us at 904-284-5618 to learn how we can help you.