Medicaid ICP Enrollment for Nursing Home Care

Enrollment in Florida’s Institutional Care Program (ICP) for Medicaid paid-for nursing home assistance is administered by Florida’s Department of Children and Families (DCF): http://www.myflfamilies.com/service-programs/access-florida-food-medical-assistance-cash/medicaid and http://www.dcf.state.fl.us/programs/access/docs/icp_brochure.pdf.

Although Florida’s Agency for Health Care Administration (ACHA) is in theory responsible for the State’s entire Medicaid program administration: http://www.fdhc.state.fl.us/medicaid/, a consumer user of the Florida Medicaid ICP Program will interact directly, or through its representatives or agents, with DCF for eligibility determination and application approval.

Back in the day, ICP applications were made directly to the county service center for DCF.  It was possible to submit the application and supporting documentation re the applicant’s family, assets, income, expenses, and debts, directly to a local case worker, and even have a brief preview of the coming application process, by a short discussion with a case worker.  Now, the process is via Internet portal, and is very impersonal: http://www.dcf.state.fl.us/ess/.  A DCF case worker is then assigned and the applicant or the applicant’s representative or agent may be asked for additional supporting information on a moment’s notice.  Hence, most experienced Elder Law attorneys who work in this area still employ the “old school” approach of building a detailed and comprehensive supporting documentation file for each ICP applicant whom they represent.  Social workers for nursing homes may also submit basic ICP applications on behalf of existing patients in residence.

It may be useful to consider how most ICP applicants come to the point of a Medicaid application for nursing home assistance.  Often, these are middle income and even upper middle income folks, who have never received yet alone applied for public assistance in the past.  However, the daunting fiscal responsibility of an average nursing home cost in Florida estimated at $7,500.00 per month for a semi-private room can send the staunchest, most independent capitalist running for the cover of state paid for nursing home assistance.  Usually, patients enter the nursing home after a hospital stay.  Traditional health care insurance does not cover a nursing home stay for custodial purposes.  Even with senior adult patients, the Medicare coverage and supplemental health care insurance coverage available in the nursing home is limited.  Best case, the Medicare patient may expect up to 20 days of nursing home coverage after a three-day hospital stay, followed by an additional reduced benefit of up to an additional 80 days, with supplement health insurance or private patient contribution picking up the co-pay responsibilities during that second 80-day max period.  In the real world, if the Medicare patient is deemed not to be making rehabilitative progress in the nursing home (e.g., refuses or is unable to progress towards release via engaging in physical and occupational therapy sessions), then the Medicare and supplement insurance benefit may cease early, and at that point forward the nursing home patient is private pay or on Medicaid ICP.

Medicaid ICP enrollment is not automatic.  It must be applied for by or on behalf of the applicant/patient, and it must be granted by DCF based on eligibility guidelines: http://www.dcf.state.fl.us/programs/access/docs/ssifactsheet.pdf.  Also, a basic chart showing the program’s asset and income limits is published in January and July each year:http://www.dcf.state.fl.us/programs/access/docs/ssi_fin_elig_chart.pdf.  However, beyond knowledge of the then current black-letter rules and limit amounts of the Medicaid ICP Program, the impact of all of the applicant/patient’s assets, income, prior transfers to family and other, home and home value, debts, long term care insurance, and family needs, must be considered prior to filing for Medicaid ICP enrollment.

Rarely does the patient or the patient’s family member directly file for this public assistance benefit.  More often than not, either a social worker at the nursing home, a private Elder Law attorney, or a private social worker/financial planner, whether licensed or not, completes and submits the online application for the applicant/patient.  If all of the surrounding circumstances affecting the applicant/patient and family are not considered, a very real price may end up being paid unnecessarily by the applicant and his/her family.

One of the absolute worst moves that anyone can make is applying for the ICP benefit too early.  The concept of applying too early arises in at least two instances.  One instance is when the applicant has made prior significant transfers within the preceding five year period.  DCF looks back five years from the date of application, aggregates all such transfers, and denies the application based on the existence of the prior transfers, and then calculates when the applicant should reapply, presuming that the applicant is still a living nursing home patient at that future point in time.  For example, a social worker at ABC Nursing Home applies for ICP enrollment for Mr. Green.  Mr. Green had made $89,440 in combined transfers to his extended family members over the preceding five-year period.  DCF would take that total amount of transfers, divide it by the monthly divisor used by DCF for computing the penalty period during which Mr. Green will be ineligible to receive benefits, which amount is $8,944 ( as of 2017), and arrives at the conclusion that he is disqualified for ten months of benefit, and should therefore not reapply until the 11th month out.  In some instances it is better to wait out the running of the five-year look back period, and privately pay for a few months on their own, prior to applying after the expiration of the five-year look back period as to such prior transfers, than to charge ahead with an application immediately.  This requires planning and coordination, and not just the blind submission of a Medicaid application for ICP.

Another “too-soon” scenario applies to a husband and wife, when just one of the spouses needs the ICP benefit.  There are two primary goals here, in addition to getting the ICP applicant approved.  The first is to keep as much of the applicant’s monthly income at home as is possible with his or her spouse.   The second is to keep as much wealth (i.e., assets) at home as possible with his or her spouse.  Charging ahead blindly with a quick ICP application may result either in a denial of the application if the stay at home spouse is deemed to have too much in the way of “countable assets” (representing wealth kept at home), or may result in a lost opportunity to keep more of the applicant/institutionalized spouse’s income at home than otherwise would be possible without prior planning with an Elder Law attorney, in advance of the actual Medicaid ICP application submission.

The consumer’s best bet is to plan in advance with a qualified Elder Law attorney who diligently and zealously represents his or her client’s interests within the bounds of the law, and who is licensed and educated on how to do exactly that!

Don’t be a victim of one size fits all planning.  Know your legal rights on Medicaid ICP planning and applications through an experienced Elder Law attorney and act accordingly!