Florida SMMC Long-Term Care Billing Guide

Statewide Medicaid Managed Care, or SMMC, is how Florida delivers most Medicaid services. The Agency for Health Care Administration describes three components: the Long-Term Care program, the Managed Medical Assistance program and the Dental program. The current generation of contracts, known as SMMC 3.0, started on February 1, 2025.

The Long-Term Care program, LTC, pays for the services that help older adults and adults with disabilities stay at home or in the community instead of a nursing home: meals, personal care, homemaking, adult day care, assisted living and more. For a provider, the key fact is simple. The state sets the rules, but the member's plan authorizes the services and pays the claims.

Since 2025 the state is divided into nine lettered regions instead of eleven numbered ones. South Florida providers deal mostly with three of them: Region G (Indian River, Martin, Okeechobee, Palm Beach and St. Lucie), Region H (Broward) and Region I (Miami-Dade and Monroe).

AHCA lists three conditions for long-term care. The person must be eligible for Medicaid; must be 65 or older, or 18 or older and eligible because of a disability; and must be found by the CARES program at the Department of Elder Affairs to need nursing home level of care, or hospital level of care for people with cystic fibrosis.

• The Department of Elder Affairs decides medical eligibility, through CARES.
• The Department of Children and Families decides financial eligibility.
• The enrollee then chooses, or is assigned, a long-term care plan in their region.

For a provider, this explains why a new client can be eligible on paper and still not billable: until a plan is in place and has authorized the service, there is nobody to send the claim to.

AHCA's list of long-term care services includes, among others, adult companion care, adult day health care, assisted living, attendant nursing care, caregiver training, home accessibility adaptation, home delivered meals, homemaker, intermittent and skilled nursing, medication administration, nutritional assessment, personal care, personal emergency response systems, respite care, the therapies and transportation to long-term care services. Plans may add expanded benefits of their own.

The coverage policy incorporated by rule 59G-4.192 defines each service. Home delivered meals, for example, are nutritionally sound meals delivered to an enrollee who has difficulty shopping for or preparing food, each providing at least 33 1/3 percent of the current Dietary Reference Intake.

AHCA's chart of the 2025 to 2030 plans shows which plans hold which contract in each region. Two plan types serve long-term care enrollees: Comprehensive Plus plans, which provide long-term care to eligible recipients, and Select Comprehensive plans, which provide both medical and long-term care to people enrolled in LTC. Read together, the chart and these definitions give the following picture.

In Miami-Dade, that means a provider can face seven different long-term care plans, each with its own provider manual, payer ID, authorization form and remittance habits.

The coverage policy is direct: long-term care services must be authorized by the enrollee's plan before they are delivered, and must match the type, amount, duration, frequency and scope written in the enrollee's plan of care. The plan of care carries the start and end date of each authorization and is reviewed at least every 90 days.

1. Get the authorization from the plan before the first service, and record its number, units and dates.
2. Deliver what was authorized, no more, and keep the service record.
3. Send the claim to the member's plan, electronically, as an 837 through the plan's clearinghouse or portal.
4. Watch the acknowledgments and the remittance, and correct any rejection quickly.

AHCA's summary of the plan contracts says a provider submits claims to the SMMC plan for services under the contract, and that plans must accept claims electronically to the greatest extent possible, acknowledge them within 24 hours and pay 85 percent of clean claims within 7 days, 95 percent within 10 days and 98 percent within 20 days. When a member changes plans, AHCA says the provider is paid by the new plan.

Individual plans publish their own filing limits in their provider manuals, sometimes counted in days rather than months. The shorter of the two is the one to plan around.

The 21st Century Cures Act requires electronic visit verification for Medicaid personal care and home health services that involve an in-home visit. In SMMC, each plan requires the EVV system of its own vendor, and since February 2025 plans file a monthly EVV report with AHCA. Several plans, among them Florida Community Care, Sunshine Health and Humana, name HHAeXchange as their vendor in their provider notices. Ask each plan which system it expects before the first visit.

PACE, the Program of All-inclusive Care for the Elderly, is a separate road. AHCA describes it as serving Medicaid and Medicare eligible people aged 55 and older in a PACE service area, and notes it is not offered by the health plans serving Medicaid enrollees. A PACE organization is paid directly by CMS and AHCA and becomes the participant's sole source of Medicare and Medicaid services, so a provider working for PACE participants bills the PACE organization under its own rules, not an SMMC plan.

Zeumatic is built in Florida, for providers who bill several long-term care plans at once. Each client carries their plan and their authorization, read from the PDF by AI and checked by the team, and the payer of a claim follows the authorization, so a member who changes plans is billed to the right one.

Claims leave through Availity with each plan's payer ID, acknowledgments and 835 remittances are matched automatically, and payments are tracked plan by plan. Renewals coming due are announced ahead of time, grouped by insurance, so an authorization does not lapse in the middle of a month.