Covering The Cost of Assisted Living in Florida: Assisted Living Waiver for the Elderly

It is difficult enough to come to terms with the reality of having to find a Skilled Nursing or Residential Care Facility for you or a loved one but to find one that is a great fit can take time and, sometimes, may take a couple of tries before a perfect “home” can be found.

The first question people ask when faced with this new reality is “where do I begin my search?” Searching for a facility through this very site, Assisted Living Directory, will make your search a little easier. Using the checklist on this site can be invaluable as well (http://www.assisted-living-directory.com/pdf/questionnaire.pdf).

The second question people tend to ask is “how can I afford to pay for this facility and these services?” Financial worry can add a great deal of stress to an already difficult (and usually unwanted) situation. The reality is assisted living can be costly. However, nationwide over 50% of residents use some form of Medicaid to pay for nursing home or assisted living care. Payment through private pay and insurance make up the balance.

Many states have created specific waiver programs within their federally funded Medicaid programs to help defray these costs. Some states do not have separate waiver programs but still help cover the costs of skilled or assisted living facilities (or home health care) through their Medicaid program. It is oftentimes difficult and confusing to navigate through these programs but the financial assistance is well worth the effort.

Florida is one state with a waiver program designed to help cover the cost of long term care. Information about the program and how to navigate the waiver system is described below.

What is ALE? The Assisted Living for the Elderly Waiver has been designed for individuals who are at risk of nursing home placement and covers three specific areas of care including case management, assisted living and incontinence supplies (if needed). Recipients must live in a Qualified Assisting Living Facility and services provided include occupational therapy, physical therapy, personal care, recreational services as well as many more. The waiver does not pay for the room and board directly but through Affordable Assisted Living facilities a person on limited income would be able to pay for the services. Additional information about specific coverage can be found at the Florida Department of Elder Affairs website (http://elderaffairs.state.fl.us/faal/operator/alemedicaid.html).

Who is Eligible? There are three parts of the eligibility process: general, medical and financial.

General Requirements. To be eligible for the Florida Assisted Living for the Elderly Waiver, a person needs to be 65 years or older or aged 60 – 64 years and disabled (according to the Social Security standards). The applicant also needs to be a resident of Florida as well as a US citizen.

Financial. Financial eligibility for the ALE requires meeting the same financial requirements of Supplemental Security Income. Income and asset limits are modified annually but for 2012 the income limit for an individual is $2,094 and the asset limit for an individual is $2,000.

Medical. Medical eligibility involves needing assistance with four or more activities of daily living or a diagnosis of Alzheimer’s Disease (or other type of dementia) or having a diagnosed degenerative condition. A person can also meet eligibility requirements if awaiting discharge from a nursing facility and who meets Assisted Living Facility criteria. To be sure of all of the eligibility requirements please check the Florida Department of Elder Affairs website.

How Do I Apply? Be prepared to provide documentation supporting financial and non-financial eligibility so gather tax documents as well as your social security card and birth certificate. It may also be helpful to have a loved one or other representative work on your behalf to become eligible for the Assisted Living Waiver. Applications must be completed by contacting the Aging Resource Center in your Planning and Service Area (PSA). A list of the Planning and Service Areas in Florida can be found through the Florida Department of Elder Affairs at http://elderaffairs.state.fl.us/doea/arc.php.

Extra Tip: If assistance is needed with financial matters at Social Security, it is possible to appoint a Representative Payee (ask how to do this at your local Social Security office). This can be useful when navigating the various programs available through Social Security. The Medicaid system will have their own additional forms to complete in order to appoint a representative.

What Happens if I am Denied? Many people are denied benefits or acceptance into the Assisted Living for the Elderly Waiver program but do not let this be discouraging news. Mistakes are made and reversals can happen. Appealing a denial is strongly encouraged. However, please note the program has limited funding and, unfortunately, not everyone who applies and meets eligibility requirements will be accepted into the program.

Keep in mind, there are always a specific set of rules for the appeals process which can bring a reversal of the denial. It is important to know the appeal process and to follow the instructions and timeline carefully. Contact the Florida Department of Elder Affairs for specific instructions on how to appeal.

Once approved for the ALE program, many care facilities are available throughout Florida to provide services and care for you or a loved one. Once this worry is resolved, the Sunshine State will be looking particularly sunny!

- Article by Trish Hughes Kreis exclusively for Assisted Living Directory