CRITERIA FOR MEDICAID ELIGIBILITY
There are four criteria, or “tests” that must be met to become eligible for the Medicaid Nursing Home Program in Florida (aka the “Institutional Care Program” or “ICP”).
These same requirements must be met when applying for Medicaid Home and Community Based Services when services are being received in a venue other than a nursing home (such as at home or in an assisted living facility).
In Florida, all Medicaid services, including long-term care in any venue, fall under the Statewide Medicaid Managed Care (SMMC)program.
The first test is residency; the applicant must be a U.S. citizen or qualified resident alien and a Florida resident. The next three, a) medical need, b) age, disability, or blindness, and c) financial need, are discussed below.
The second test is medical need. The definition of medical need with respect to Medicaid is a bit more fluid than with respect to Medicare.
The care provided to the individual need not be strictly medically necessary, but may be custodial in nature. The person must have some form of impairment, physical or cognitive, that limits their activities of daily living to a point where nursing home level of care is needed or where it is determined that life or health will be endangered without such care.
In Florida, medical need is ascertained by the Comprehensive Assessment and Review of Long-Term Care Services (CARES) unit of the Department of Elder affairs. This unit performs the federally mandated function of conducting nursing home pre-admission screening and assessment for Medicaid long term care programs.
Persons who are applying for Medicaid nursing home care are assessed by either a CARES nurse or social worker with medical review by a physician prior to approval. There is no charge for the assessment which also must be performed for those applying for Home and Community Based Services.
Age, Disability, or Blindness
The third test requires that the applicant either have some form of disability, be over 65, or blind. A 60 year old with Alzheimer’s would meet this test as the effects of Alzheimer’s (being unable to function safely alone) qualifies as a disability. A seventy year-old, on the other hand, need not have a disability as long as he or she meets nursing home level of care criteria as described above.
The fourth test, financial eligibility, has the most confusing requirements and can be the most difficult to meet due to the number of variables that must be considered and the complexity of the applicable rules.
Generally speaking, there are two “sub-tests” under the banner of financial eligibility: The “Asset Test” (what the applicant owns) and the “Income Test” (how much earned and unearned income the applicant receives).
What is considered an asset and what is not? What is considered income and what is not? What about the house? Not surprisingly, the answers are not as simple as we would like.
We start with the Income Test. A link for a discussion of the Asset Test is also on the next page.