An Open Letter Regarding the Florida Medicaid Diversion Program
Medicaid Diversion is a program that provides financial assistance with the cost of assisted living care. Medicaid pays for long term care services in most states. Each state can decide what services its Medicaid program will cover, and every state has different coverages. In Florida, only nursing home care is a mandatorily covered service. Therefore, in order to obtain Medicaid benefits for persons in Assisted Living facilities, the state Medicaid agency has created a program which “diverts” funds from nursing homes to ALFs (known as “diversion), or which “waives” the requirements of the current state Medicaid plan for persons living in ALFs (Medicaid “waiver” programs). This letter addresses the diversion program. Whether for diversion or waiver, applicants must meet the same medical level of care as they would need to be covered in a nursing home. In this way, the Medicaid program can show that it has saved money by keeping individuals out of nursing homes and in the less expensive, less restrictive setting of an ALF. Unlike Medicaid at the nursing home level, Diversion pays a lump sum amount and does not offer full coverage of care or medications. The premise behind the program is to allow those who would otherwise qualify for skilled nursing to live in an assisted living facility where they can be safely cared for at a reduced cost to the state. Unfortunately funding is often depleted before everyone is served and there is a long wait list maintained by the Department of Elder Affairs in Tallahassee.
The program currently works like this:
The providers (American Eldercare, Citrus, Universal, and Evercare) contract with the state to provide care to “at risk elders” in assisted living facilities. They contract to provide services (care services) and their responsibilities are laid out in a 121 page contract with the state. The contract states that the amount paid to the provider covers all services and the facility may not bill separately for care services. This means they cannot charge an additional fee for level of care.
The providers then contract with each individual facility and negotiate a rate whereby the facility agrees to provide the elder with the needed services. This rate is different depending on the provider and the room and board rate established by the facility. For example, American Eldercare may pay $1000 to one facility and $1200 to another. This amount is covers all services and is deducted from the total room rate. If the difference is more than the resident’s income the facility has the right to ask the resident to pay the difference- but only for the room- not for services.
The providers each have a menu of additional services they may choose to provide, such as a medication stipend (to cover medication co-pays) or incontinence supplies. The resident has the right to talk to all providers and find the one that best suites their needs- they are only limited by the fact that each facility chooses who they wish to contract with. Some facilities work with only one provider, some work with all 4 providers.
So, the bottom line is that you have to shop around for the best rate. In one facility I spoke to, they work with 3 of the providers. They have residents on Medicaid diversion under each of the providers and the residents all pay different amounts. Some pay only the income they have, some pay an additional room charge, and some pay all the room charge but have income left over. Again, it depends on the negotiated rate set by the facility and by the provider and of course the amount of income available. I also learned that the facility can charge less than the contracted rate but cannot charge more.
When talking with the admissions office at the facilities I would suggest you be very honest about the resident’s income and the family’s ability to cover additional costs. If the resident’s income is not sufficient, and the family cannot help, and the facility will not work with you on the rate, then I suggest you go somewhere else. If there are funds to cover the cost of care while awaiting diversion then you might try to negotiate a private pay rate until diversion and then income plus diversion once approved. For most of my clients this has been the case and the families have never been asked to pay additional level of care costs. The only additional cost has been when the resident wants a private room vs. a shared room. With the state of the economy many facilities are having a hard time filling beds and at the same time reducing the rates as they, like everyone else, are feeling the pinch and trying to increase the bottom line.
We are doing our best, as advocates for our clients, to educate the families, and when necessary, to remind those in charge of admissions at the ALFs how the program works and what, if any, additional charges may be passed along to the resident. Feel free to call our office if you would like an appointment to discuss if the Medicaid Diversion program is right for you or your loved one.
Teresa K. Bowman, Esq.
