Mom Needs Assisted Living Now but Medicaid Is Still Pending — What Florida Families Do

In this article

1. Find out which kind of pending you are in
2. Rule out the payback first
3. How long the decision takes
4. If she is already in a nursing home
5. The order to work through it
6. The question to ask before you tour
7. Covering the months in between

When your mom needs assisted living now and her Medicaid is still pending, Florida families usually bridge the gap in one of four ways: pay privately for the first months, use savings that would have to be spent down anyway, ask a family member to cover a set share until a decision arrives, or, if she is already in a nursing home, use the transition route that skips the waitlist. What does not work is waiting for Medicaid to pay back the months before it starts, because for most Florida adults it does not.

Find out which kind of pending you are in

Families say "Medicaid is pending" about two very different situations, and the next step depends on which one it is.

The first is a financial application that has not been decided. The Florida Department of Children and Families is still reviewing her income and assets, and nothing will move until it mails a notice.

The second is harder to see. She may already be financially eligible and medically approved by the state's CARES nurses, yet still sitting on the pre enrollment list for the long term care program. Under section 409.979 of the Florida Statutes, the Department of Elder Affairs releases people from that list by a priority score based on frailty, and only when funding allows. A tie goes to whoever has waited longest, but a long wait alone does not move her up.

Call DCF at (866) 762-2237 about the first. Call the Elder Helpline at (800) 963-5337 about the second, and ask for her current status with the Aging and Disability Resource Center. Those two calls tell you whether you are waiting on paperwork or waiting on a spot.

Rule out the payback first

The most expensive misunderstanding in this situation is the belief that Medicaid will reimburse the private months once it approves her. For most adults in Florida, it will not.

The Agency for Health Care Administration ended the three month retroactive eligibility period for adults 21 and older who are not pregnant, effective February 1, 2019. Eligibility now begins on the first day of the month the application is received. A family that waits until the end of a month to file can lose a whole month of coverage by a few days.

That gives you the single most useful thing to do this week. If the financial application has not gone in yet, file it now through MyACCESS or by phone, before the move, before every document is gathered, and before the end of the month.

How long the decision takes

Federal Medicaid rules at 42 CFR 435.912 set an outside limit of 45 days for most applicants and 90 days for someone applying on the basis of disability. Most aging parents fall under the 45 day standard.

Florida's own eligibility rule does not count delays the applicant causes, such as a missed interview or a bank statement that never arrived. In practice, the clock you control is the paperwork. Answer every DCF request the day it arrives, keep copies, and write down the name of each person you speak with.

The waitlist has no deadline like that. Release depends on her priority score and on how much room the program has, which is why the resource center is the only place that can tell you where she stands this month. If her health changes while she waits, a fall or a new diagnosis, call them back and ask whether a new screening is needed, since the score comes from the screening.

If she is already in a nursing home

This is the exception most families never hear about. Florida law lets a nursing home resident who has lived in a Florida licensed skilled nursing facility for at least 60 consecutive days, and who asks to move into the community, enroll in the long term care program without going through the waitlist, as long as every other requirement is met.

If your mom went from the hospital into rehab and is still there, ask the nursing home social worker today how many days she has been a resident and whether this transition applies to her. The same section gives priority to someone referred by DCF's Adult Protective Services as high risk.

The order to work through it

Start the first two rows the same day. They are separate offices, and neither one will tell you about the other.

The question to ask before you tour

Here is the part that works against us as much as anyone. A community decides for itself whether to accept Medicaid, and it also decides whether to admit someone whose Medicaid has not come through. Some will not. Even a community that does accept Medicaid, ours included, may not have a Medicaid supported room open the week you need one. Approval in Tallahassee does not guarantee a bed anywhere in Citrus County.

So the first question on every call is not about activities or dining. Ask whether they will admit her while Medicaid is pending, what she would pay privately in the meantime, and what changes on the day her enrollment begins. A straight answer to those three tells you more than a tour will.

Sugarmill Manor in Homosassa and The Gardens in Crystal River both accept Medicaid, in assisted living and in the secured memory care section. Our page on assisted living that accepts Medicaid in Citrus County covers how that works at both, and we publish a starting price for every room, so you can see what a private month costs before you call.

Covering the months in between

The gap is usually measured in weeks to a few months, not years, and a short, specific plan works better than an open promise.

If her savings are above the Medicaid limit, money spent on her own care during the wait is often part of reaching that limit anyway. Ask DCF how her particular assets are counted before anything is sold or moved, because the wrong transfer can delay the approval you are waiting for. Our post on Medicaid spend down for assisted living in Florida covers that in more depth.

If family is helping, put it in writing between you: who pays what, starting when, and until which event. Three siblings covering a set share until her enrollment begins is a plan everyone can live with.

If she cannot be safely alone this week and nothing is settled, a short respite stay can give you somewhere safe for her while the paperwork finishes. Medicaid usually does not pay for respite, so treat it as a private bridge and call to arrange the dates.

For the wider picture of every way Florida families pay, our guide to what to do if you cannot afford assisted living in Florida walks through Medicaid, the state supplement, VA benefits, and long term care insurance side by side. And if you would rather write than call, our contact page reaches the same people.

Frequently asked questions

Can my mom move into assisted living while her Medicaid is still pending in Florida?

Sometimes. Each community decides whether to admit a resident whose Medicaid has not come through, and many families pay privately for the first months. Ask that question on the first call, along with what she would pay in the meantime.

Will Florida Medicaid pay back the months before she was approved?

For most adults, no. Florida ended the three month retroactive period for adults 21 and older who are not pregnant in 2019, so coverage starts no earlier than the first day of the month the application is received. Filing early protects that month.

How long does a Florida Medicaid application take to decide?

Federal rules allow up to 45 days for most applicants and 90 days when the application is based on disability. Delays the applicant causes, like a missing document, do not count against that limit, so send every request back quickly.

Can someone in a nursing home skip the Florida long term care waitlist?

Yes, under Florida law, a resident of a licensed skilled nursing facility for at least 60 consecutive days who asks to move into the community can enroll without the waitlist, if every other requirement is met. Ask the nursing home social worker.

Sources

• Florida Agency for Health Care Administration: Medicaid retroactive eligibility
• Florida Statutes section 409.979: long term care program eligibility and enrollment priority
• 42 CFR 435.912: timeliness standards for Medicaid eligibility decisions
• Florida Administrative Code rule 65A 1.205: eligibility determination process
• Florida Department of Elder Affairs: Medicaid long term care program and the Elder Helpline
• Florida Department of Children and Families: public assistance

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Written by

Cameron Hernando Clark

Community Relations Director

Cameron Hernando Clark is the Community Relations Director for The Manors of Citrus. He writes this family guide to help Citrus County families make sense of assisted living and memory care, drawing on the day to day of running two family owned communities on Florida's Nature Coast.