Assisted living facilities (ALFs) in Florida provide a residential setting that combines apartment-style living with support services for individuals who require assistance with daily activities, such as dressing, bathing, medication management, and mobility. While ALF costs can be substantial, Florida’s Medicaid program offers financial help for eligible residents. It is important to understand that Medicaid does not cover the complete cost of living in an ALF. Specifically, it will not pay for “room and board,” which includes housing, utilities, and meals. Medicaid’s financial assistance is strictly designated for the personal care and medical services provided within the facility.
Understanding Florida’s ALF Medicaid Structure
Florida provides Medicaid support for assisted living through the Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) Program. This program is not an entitlement, meaning slots are limited, and eligible applicants may face a waitlist. The SMMC-LTC program functions as a Home and Community-Based Services waiver, designed to help individuals requiring a nursing facility level of care remain in a community setting, such as an ALF.
The financial assistance is delivered through a managed care model. Participants choose a long-term care plan from a Managed Care Organization (MCO) operating within their geographic region. The MCO coordinates and pays for a comprehensive list of long-term care services provided to the resident. Covered services include personal care assistance, medication administration, attendant nursing care, and therapies.
The MCO contracts directly with participating assisted living facilities to cover the costs of these care services. This mechanism essentially subsidizes the personal care component of the ALF bill. The SMMC-LTC program explicitly excludes payment for the resident’s room and board costs.
Eligibility Requirements for the Waiver Program
Qualifying for Medicaid assistance for assisted living involves meeting a dual set of criteria: financial and functional.
Financial Eligibility
The financial eligibility requirements are determined by the Florida Department of Children and Families (DCF). For a single applicant, countable assets must generally be valued at $2,000 or less, with income limits set at a specific cap that changes annually. If an applicant’s income exceeds this cap, they may still qualify by establishing a Qualified Income Trust, dedicating the excess income toward their medical costs. Certain assets, such as the applicant’s primary residence (up to a specific equity limit), personal belongings, and one vehicle, are considered non-countable. When only one spouse is applying, spousal impoverishment rules allow the non-applicant spouse to retain a significantly higher amount of the couple’s combined assets.
Functional Eligibility
The functional or medical eligibility is determined by the Department of Elder Affairs (DOEA). Applicants must demonstrate they require a Nursing Facility Level of Care (NFLOC) to qualify for the SMMC-LTC program. This medical necessity is assessed through the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program. The CARES assessment evaluates the applicant’s ability to perform Activities of Daily Living (ADLs), such as transferring, dressing, bathing, and eating, to certify the need for long-term care services.
Locating Participating Assisted Living Facilities
Finding an assisted living facility that accepts Medicaid requires confirming its contractual relationship with the SMMC-LTC program’s MCOs. Not all licensed ALFs contract with the program, and those that do may not contract with every MCO. The facility must be part of the network of the specific MCO the resident is enrolled with through the Medicaid waiver.
A practical first step is to contact the Florida Agency for Health Care Administration (AHCA), which administers the SMMC-LTC program. AHCA maintains resources and directories of licensed facilities that participate in the Medicaid waiver. Local Aging and Disability Resource Centers (ADRCs) are also valuable resources, providing regional information and guiding individuals through the application and selection process.
Once approved for the SMMC-LTC waiver and assigned to an MCO, the individual should contact the MCO’s member services department. The MCO is required to provide a list of assisted living facilities within their network that are accepting new residents. This direct confirmation is necessary because facility participation can change, ensuring the chosen ALF is prepared to accept the Medicaid reimbursement for services.
Remaining Costs and Financial Responsibilities
Even with SMMC-LTC program coverage, the resident is responsible for the full cost of room and board. This remaining out-of-pocket expense is often referred to as the patient share or cost-share, covering housing, meals, utilities, and general maintenance of the ALF.
The amount the resident must pay is calculated based on their monthly income. Medicaid rules require that nearly all of the resident’s income be contributed toward their cost-share, with the exception of a small Personal Needs Allowance (PNA). The PNA is a set monthly amount, currently around $160, that the resident keeps for personal expenses.
The remaining income after the PNA deduction is paid directly to the assisted living facility for room and board. Facilities accepting Medicaid must adhere to state regulations regarding the maximum charge for room and board for SMMC-LTC residents. This structure ensures the resident’s financial contribution is directly tied to their available income.