The Florida Statewide Medicaid Managed Care (SMMC) program represents a significant shift in how long-term care and medical assistance are delivered to eligible individuals in Florida. Established by the Florida Legislature in 2011, this program, overseen by the Agency for Health Care Administration (AHCA) and the Department of Elder Affairs, fundamentally changed the landscape of Florida Medicaid. SMMC is designed to provide comprehensive and coordinated care through two distinct yet interconnected programs: the Long-Term Care (LTC) Managed Care Program and the Managed Medical Assistance (MMA) Program. This guide will focus on providing a detailed overview of the Florida Statewide Medicaid Managed Care Program, with a particular emphasis on the Long-Term Care component relevant to those seeking support for extended care needs.
Florida Medicaid
Understanding the Two Pillars of SMMC
The Statewide Medicaid Managed Care program is structured around two core programs, each addressing distinct healthcare needs within the Florida Medicaid system.
Long-Term Care (LTC) Managed Care Program
The Long-Term Care (LTC) Managed Care Program is specifically designed for Medicaid recipients who require long-term care services, often due to age or disability. This program is crucial for individuals who need assistance with daily living activities and may require care at a nursing home level but desire to receive care in their homes or community settings whenever possible. Enrolling in the SMMC LTC program means that eligible individuals receive their long-term care services through a managed care plan, ensuring coordinated and comprehensive support. The primary aim of the LTC program is to provide the necessary services to allow individuals to maintain their independence and quality of life while delaying or preventing the need for nursing facility placement.
Managed Medical Assistance (MMA) Program
While the focus of this guide is on long-term care, it’s important to acknowledge the second component of SMMC: the Managed Medical Assistance (MMA) Program. MMA encompasses a broader range of medical services for Medicaid recipients who do not require long-term care services. This program ensures that individuals receive essential healthcare services through managed care plans, promoting access to medical care and preventative services.
Eligibility for SMMC Long-Term Care
To be eligible for services under the SMMC Long-Term Care program, individuals must meet specific criteria related to age, disability, and the level of care needed. The eligibility requirements are as follows:
- Age 65 and over and eligible for Medicaid: Seniors aged 65 and older who qualify for Florida Medicaid are eligible to apply for the SMMC LTC program.
- Age 18 and over and eligible for Medicaid by reason of a disability: Adults between 18 and 64 years of age who are eligible for Medicaid due to a qualifying disability can also access SMMC LTC services.
- Nursing Home Level of Care Determination: A critical eligibility requirement is the determination by the Comprehensive Assessment and Review for Long-Term Care Services (CARES) unit at the Department of Elder Affairs that the individual requires a nursing home level of care. This assessment ensures that services are directed to those with significant long-term care needs and involves meeting established clinical criteria. You can learn more about the CARES program and assessment process by visiting the CARES website.
Meeting these eligibility criteria is the first step in accessing the comprehensive long-term care services offered through the Florida Statewide Medicaid Managed Care program.
Services Provided Under SMMC LTC
The SMMC Long-Term Care program offers a wide array of services designed to support individuals in various aspects of their daily living and healthcare needs. These services are tailored to meet medical necessity and are aimed at preventing or delaying nursing facility placement. The comprehensive list of services available through each managed care plan contracted with AHCA includes:
-
Personal Care Services:
- Adult Companion
- Attendant Care
- Personal Care
- Homemaker
-
Adult Day and Respite Services:
- Adult Day Care (Adult Day Health Care)
- Respite Care
-
Home and Environmental Modifications:
- Home Accessibility Adaptation
- Home Delivered Meals
- Personal Emergency Response System
-
Skilled and Therapy Services:
- Intermittent and Skilled Nursing
- Occupational Therapy
- Physical Therapy
- Respiratory Therapy
- Speech Therapy
-
Medical and Health Management:
- Assistive Care Services
- Behavior Management
- Caregiver Training
- Case Management
- Hospice
- Medical Equipment & Supplies
- Medication Administration
- Medication Management
- Nutritional Assessment and Risk Reduction
-
Facility Based Care & Transportation:
- Assisted Living Facility Services
- Nursing Facility Care
- Transportation
It’s important to note that access to these services is determined based on individual medical necessity and the specific needs outlined in the care plan developed with the managed care plan.
Independent Consumer Support Program (ICSP): Your Advocate
Navigating the complexities of managed care programs can be challenging. The Independent Consumer Support Program (ICSP) is a valuable resource established to assist consumers enrolled in the SMMC LTC program. This coordinated effort involves the Florida Department of Elder Affairs’ Bureau of Long-Term Care & Support (LTCS), the statewide Long-Term Care Ombudsman Program (LTCOP), local Aging and Disability Resource Centers (ADRCs), and AHCA.
The ICSP provides multiple access points for consumers to seek information, address complaints, file grievances or appeals, and get answers to their questions. This “no wrong door” approach ensures that consumers can easily find assistance regardless of their initial point of contact. The collaboration between LTCS, ADRCs, and LTCOP ensures that consumers are directed to the most appropriate resource for their specific needs, streamlining the resolution process and empowering consumers to effectively navigate the SMMC LTC program.
Accessing More Information and Support
For individuals seeking more detailed information about the Florida Statewide Medicaid Managed Care Long-Term Care program and the resources available, the following websites and contact points are invaluable:
-
AHCA Statewide Medicaid Managed Care Website: For a comprehensive program overview and summary, visit the official AHCA website dedicated to SMMC LTC: http://ahca.myflorida.com/Medicaid/statewide_mc/smmc_ltc.shtml
-
Choice Counseling Website: To explore the LTC plans available in each region of Florida and for guidance on choosing a plan that best meets individual needs, visit the Choice Counseling website: www.flmedicaidmanagedcare.com
-
Local Aging and Disability Resource Centers (ADRCs): For information regarding the SMMC LTC waitlist and direct assistance in your local area, contact your local ADRC. A directory of ADRC contacts is available for each region. You can also reach out to the statewide Elder Helpline at 1-800-96-ELDER for immediate support.
-
AHCA Complaint Reporting: If you need to file a complaint regarding your LTC plan, you can do so through the AHCA website. Visit http://ahca.myflorida.com/SMMC and click on the “Report a Complaint” button for instructions and the complaint form.
The Florida Statewide Medicaid Managed Care program is a crucial system for providing long-term care and medical assistance to eligible Floridians. By understanding the program’s components, eligibility criteria, available services, and support resources like the ICSP, individuals and their families can effectively access the care and assistance they need.
