How does the Long-Term Care Waiver operate, in a nutshell?

Florida’s Agency for Health Care Administration (AHCA) has the ultimate responsibility for the LTC Waiver, but the actual operation is through a managed care model. AHCA contracts with managed care plans (typically private insurance companies) to run the program and pays the plan a set rate for each person the plan enrolls.

When a person enrolls, they must select a plan in their region or the state will make a selection for them.

The plan will then assign the enrollee a case manager to visit, explain the program, and help put together a care plan. It is the case manager’s responsibility to make any requests for services to the plan, and the plan’s responsibility to determine if the requested services are medically necessary and to issue a written notice if services are denied, reduced or terminated.

Once services are authorized, the enrollee can chose a service provider from the network of providers who have contracted with the plan. If a provider can’t be located, the plan should make provisions for use of out-of-network providers.

What is the goal of the LTC Waiver?

According to the Florida rule that governs service coverage for the LTC Waiver, managed care plans are “required to provide an array of home and community-based services that enable enrollees to live in the community and to avoid institutionalization.” Rule 59G-4.192, Fl. Admin. Code, adopting the SMMC Long-term Care Program Coverage Policy.

Is the LTC Waiver a stepping stone to nursing home care?

No! Like ALL HCBS Waiver, enrollees must meet an institutional level of care (in this case, the institution is a nursing home.) So the LTC Waiver is a choice to seek care in the home or in a community setting (like an assisted living facility) rather than enter a nursing home.

What kind of services does the LTC Waiver offer?

All enrollees have a care coordinator or case manager. Direct care services include both skilled (private duty nursing and skilled nurse visits), and unskilled (personal care, companion, homemaker, adult day care, temporary respite, support for assisted living). A variety of other services are available, like therapies, home-delivered meals, and even accessibility adaptations for the home.

Is there a limit on the amount of services?

There is no set cap on covered services. The only limit is that the service must be medically necessary.