Florida Medicaid

Florida Medicaid Explained

What is Medicaid?

Medicaid provides health coverage to more than 66 million Americans, including eligible low-income adults, newborns and children, pregnant women, elderly adults and people with disabilities. It is administered by individual states according to federal requirements. State and federal governments share costs for the Medicaid program.

In Florida, Medicaid is administered by the Agency for Health Care Administration.  It is the chief health policy and planning entity for Florida and oversees a $25 billion budget for Medicaid that serves more than 4.2 million of the state’s residents who receive Medicaid benefits.  The agency also oversees licensing for more than 48,000 health care facilities and is responsible for sharing important data that helps shape public health policies in the state.

AHCA administers the Statewide Medicaid Managed Care (SMMC) program.  Most Florida Medicaid recipients are enrolled in the SMMC Program. It has three components: Long-Term Care (LTC) program, Managed Medical Assistance (MMA) program, and the Dental program.

Medicaid eligibility in Florida is overseen by the Florida Department of Children and Families (DCF) or the Social Security Administration for those people who receive SSI benefits.

DCF’s Automated Community Connection to Economic Self Sufficiency (ACCESS) is a system that allows customers to connect with the public assistance information, including Florida Medicaid, 24/7 after they set up a MyACCESS account.

ACCESS Florida promotes strong and economically self-sufficient communities by determining eligibility for food, cash and medical assistance for individuals and families.

Florida Medicaid has services for many scenarios.

• Florida Medicaid for AdultsFlorida Medicaid for Seniors
• Florida Medicaid for Elderly
• Florida Medicaid for Assisted Living
• Florida Medicaid for Autism: This falls under the federally mandated medicaid benefits.
• Florida Medicaid for Long Term Care
• Florida Medicaid for Nursing Homes
• Florida Medicaid for Mental Health
• Florida Medicaid for Dental

The Difference Between Medicaid and Medicare

The federal government administers two healthcare related programs to assist individuals.  One is Medicaid and the other is Medicare.  Although they sound alike and are sometimes confused with each other, they are distinctly different.

The main difference is that Medicaid is an assistance program and Medicare is an insurance program. 

Medicare helps people who are 65 and over or who have qualifying conditions under age 65 by providing coverage for their medical bills.  Medicare is divided into four parts known as Part A, Part B, Part C and Part D.  Each provides certain types of coverage.  For some services and coverages, beneficiaries may need to pay a monthly premium.  If a person has paid into Medicare throughout their working life, then some parts of Medicare will be free.  Medicare is strictly a federal program and is administered uniformly throughout the United States.

Medicaid is an assistance program and has no age restrictions.  It is based purely on need and will provide benefits if a person falls below certain income and asset levels.  Most all services are provided at no cost, except in a few limited cases.  Although Medicaid adheres to federal guidelines, it is administered by state and local governments.

Who Qualifies for Florida Medicaid?

In Florida, the Department of Children and Families (DCF) determines eligibility for public assistance programs, including Medicaid.  Federal regulations and Florida Statute and Administrative Rules contain the specific polices that must be adhered to for eligibility.  For those people who receive Supplemental Security Income, the Social Security Administration will determine eligibility.

He or she who qualifies for Florida Medicaid must be a U.S. citizen or a qualified non-citizen, must be a Florida resident, and must provide Social Security numbers to facilitate data matching.  Eligibility may be verified electronically through the Federal Data Services Hub.

Applicants must also apply for all benefits to which they are entitled including pensions, Social Security and Medicare benefits.  Income from wages and self-employment is also used to determine eligibility as well.

Family-Related Medicaid is based on need and there are strict income limits for those who want to receive benefits. Income limits are based on the expected tax filing status for each applicant.  A household’s countable income, after allowable deductions, must be less than the applicable income limits.  To view the 2018 limits for each target group, go here.

Households with income that exceeds limits for Family-Related Medicaid will be enrolled in the Medically Needy Program.  Those applicants may be referred to the Federally Facilitated Marketplace or the Children’s Health Insurance Program.

There are several targeted groups who are potentially eligible for Medicaid:

• Parents and caretaker relatives of children
• Children under age 19
• Children from 19 to 21
• Newborns and infants under age 1
• Pregnant women
• Former foster care children between 18 and 26 years old
• Non-citizens with medical emergencies
• Aged or disabled individuals not currently receiving Supplemental Security Income (SSI)

People may also be eligible for Medicaid for up to three months prior to the date they apply if they have unpaid medical bills for one or more of the three months preceding the month that they apply.  This is known as retroactive Medicaid and individuals will be notified by mail if it is determined they are eligible.

Medicaid is authorized for a 12-month period and to continue receiving coverage, a beneficiary must complete and submit a renewal annually.  All beneficiaries are required to report any changes that may affect their eligibility within 10 days of an event taking place.  Some of the examples of changes affecting eligibility may include:

• Florida Medicaid for Pregnancy
• Florida Medicaid for Newborns
• New or increased earnings
• Termination of employment
• Arrival or departure of members in a household
• A change in address
• A change in living arrangements
• Relocation to another state

What Does Florida Medicaid Cover?

States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. Federal law requires states to provide certain “mandatory” benefits and allows states the choice of covering other “optional” benefits.

Mandatory benefits include services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services like prescription drugs, case management, physical therapy, and occupational therapy.

Federal Mandatory Medicaid Benefits

Following are the federally-mandated Medicaid benefits:

• Inpatient hospital services
• Outpatient hospital services
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Nursing facility services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Family planning services
• Nurse midwife services
• Certified pediatric and family nurse practitioner services
• Freestanding birth center services (when licensed or otherwise recognized by the state)
• Transportation to medical care
• Tobacco cessation counseling for pregnant women
• Autism Spectrum Disorder (Autism)

Florida Medicaid Covered Services

In addition to the required medicaid services, Florida Medicaid also covers several additional services.  Click on the link to each of these services to get more detailed information:

• Allergy Services
• Ambulatory Surgical Center
• Anesthesia Services
• Assistive Care Services
• Behavioral Analysis
• Behavioral Health Overlay Services
• Birth Center and Midwife Services
• Cardiovascular Services
• Certified School Match Program
• Certified Substance Abuse County Match
• Chiropractic Services
• Community Behavioral Health Services
• County Health Department (CHD) Services
• Dental Services
• Dialysis Services
• Durable Medical Equipment (DME) and Medical Supplies
• Early Intervention Services
• Evaluation and Management Services
• Family Planning Waiver Services
• Federally Qualified Health Center Clinic Services
• Gastrointestinal Services
• Genitourinary Services
• Hearing Services
• Home Health Services
• Hospice Services
• Hospital – Inpatient
• Hospital – Outpatient
• Hospital – State Mental Health
• Integumentary Services
• Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Services
• Laboratory Services
• Medical Foster Care (MFC) Services
• Neurology
• Nursing Facility
• Oral and Maxillofacial Surgery Services
• Orthopedic Services
• Pain Management Services
• Podiatry Services
• Prescribed Drug Services
• Prescribed Pediatric Extended Care (PPEC) Services
• Program of All-Inclusive Care for the Elderly (PACE)
• Radiology and Nuclear Medicine Services
• Redirections
• Reproductive Services
• Respiratory Services
• Rural Health Clinic Services
• School-Based Services Programs – County Health Department (CHD) Program
• Specialized Therapeutic Foster Care
• Statewide Inpatient Psychiatric Program Services
• Targeted Case Management – Child Health
• Targeted Case Management – Children at Risk of Abuse and Neglect
• Targeted Case Management – Mental Health
• Therapy Services – Occupational
• Therapy Services – Physical
• Therapy Services – Respiratory
• Therapy Services – Speech-Language Pathology
• Transplant Services
• Transportation – Emergency
• Transportation – Non-Emergency
• Visual Aid Services
• Visual Care Services

What is the Medically Needy Program?

This program can help pay for Medicaid-covered services. Beneficiaries enrolled in this program have income or assets that exceed the limits for regular Medicaid.

Before Medicaid benefits can be approved, an enrollee must meet their “share of cost” meaning that they must pay a portion of the medical bills they incur before Medicaid benefits kick in.  This is similar to what a deductible would be in a health insurance policy.  The amount of “share of cost” is based on a family’s monthly income.

Once an individual meets the share of cost for the month, the individual must contact DCF to complete bill tracking and approve Medicaid for the remainder of the month.

Information about this program can be found in the Medically Needy Brochure.

What is the Florida Medicaid Waiver Program?

The Florida Medicaid waiver helps elderly and permanently disabled adults at risk of being placed in a nursing home to remain living in their own homes or those of their caregivers while receiving assistance.  The waiver also includes adult day care to give respites to caregivers to go to work while also caring for an aging parent.

When an application is made, applicants are assessed to determine what level of care they require.  They can be approved for any of the following benefits:

• Adult day health care
• Attendant care
• Case management
• Chore services
• Disposable medical supplies
• Durable medical equipment
• Home delivered meals
• Homemaker services
• Nutritional risk reduction (counseling)
• Personal care
• Pest control
• Respiratory therapy
• Respite care
• Skilled nursing (however not for long term)

To qualify, persons under 65 must be certified as disabled by the Social Security Administration.

Florida Medicaid for seniors 65 and older do not need to be fully disabled but must require nursing home level care.

Waiver participants must also qualify for Florida Medicaid with a determination based on income and financial resources.  The spouse who is not applying is allowed to keep sufficient income to all him or her to keep living independently.

It should be noted that demand exceeds available resources for this program and as such waiting lists to receive services are normal.

To apply, persons under 60 years of age should contact the Florida Department of Children and Families. Persons 60 and older should contact the Department of Elder Affairs.

When is Florida Medicaid Open Enrollment?

People can apply for Medicaid at any time in Florida.  Those who are accepted can also make changes in their plan online, by phone or in person at statewide customer service centers.

Medicaid applications in Florida can also be filed through the Health Insurance Marketplace for those seeking coverage.  Open enrollment for Marketplace insurance is typically offered for those who may not qualify for Medicaid or who may want different benefits than what Medicaid offers.  Open enrollment runs for about six weeks in October, November or December each year and gives applicants the ability to sign up for healthcare coverage during that time.

There are also supplemental enrollment periods that accommodate people who may qualify due to life events such as losing other coverage, getting married or having a baby.

Where Do I Apply for Florida Medicaid?

The easiest way to apply for Florida Medicaid is online by completing an application you will find here.

Applications can also be turned in at any of the ACCESS Service Center locations found throughout Florida.  To find the location nearest to you, go here.

Florida also works with several community partner agencies that help the Department of Children and Families provide access to all forms of public assistance.  This includes applying for food stamps, cash or Medicaid.  To find a local community partner agency near you, go here.

How Do I Apply for Medicaid in Florida?

You can apply for Florida Medicaid online by completing an application you will find here.

You can also complete a hard copy paper application that can be mailed, faxed or returned in person to any ACCESS Service Center location.

To get a hard copy of the Florida Medicaid application, go here.

There are also several community partner agencies that help the Department of Children and Families provide access to all forms of public assistance, including Medicaid. To find a local community partner agency near you, go here.

You will need to provide your full name, Social Security number and birthdate as well as any citizenship or immigration documentation.  Income and employer information will also be required, and you will also need to provide details on any existing healthcare coverage or potential healthcare coverage through your employer.

What Happens After I Apply for Florida Medicaid?

After you submit an application, it can take up to 30 days to process your request.  If you need a disability determination, the process could take longer.  If you signed up for email alerts when you created your MyACCESS account, you will be sent a notification when there is something posted to your account.  If you didn’t sign up for email alerts, you will be sent notices by the U.S. mail.

When your application is reviewed, it may be determined that you will need to be interviewed to get more information about your situation.  If this is the case, you will be contacted by phone to arrange for the interview.

If it is determined that you need to provide more information, you will be sent a notice detailing what is needed, along with a deadline to provide the information.  Several items may be requested, including proof of identity or citizenship, proof of earned and unearned income by providing check stubs, child support information or notices from other government agencies.  You can fax, mail or upload these documents to your MyACCESS account, or turn over the information at a local Community Center partner.

After you have completed these steps, it may take an additional 30 days to process your application.

If your application is approved for food or cash assistance, you will be mailed an Electronic Benefits Transfer (EBT) card, or you can use an existing card if you received benefits within the past 24 months.

If you are eligible for Medicaid, you will receive a gold card in the mail for all eligible members as well as Medicaid Choice Counseling information.  You will present this gold card when you receive Medicaid covered services through your provider.  If you picked a plan while your application was being processed, you will be enrolled in that plan. If you did not pick a plan while your application was being processed, a plan will be chosen for you.

If you are denied Medicaid benefits, you will receive a notice in the mail or through your MyACCESS account explaining why you did not qualify for benefits.  You have the right to appeal a denial.

Applicants determined not eligible for Medicaid will be referred electronically to the Federally Facilitated Marketplace or Florida KidCare.

How Do I Change My Florida Medicaid Plan?

After you have enrolled in a Medicaid plan, you can change your choice in several ways.

The easiest way is to go online to the Statewide Medicaid Managed Care page and log on to your account.  From there you will be taken through the steps to make your desired changes.

If you can’t make a change online, you can access the MMA automated phone system at 1-877-711-3662.  You will need your pin number to access your account

Florida Medicaid also offers counselors that are available to assist with changes by calling 1-877-711-3662, Monday through Thursday, 8 am to 8 pm, and Friday from 8 am to 7 pm.  TDD users only should call 1-866-467-4970.

You will need to make sure you have your Florida Medicaid number or Social Security number and birth year for each person you want to make changes.

How Do I Cancel My Florida Medicaid Plan?

To cancel your Florida Medicaid coverage, you will need to call the DCF at 866-762-2237 if you currently reside in Florida.  If you live outside Florida, you will need to contact Florida medicaid to determine the proper process.  Most states will provide a mailing address, we strongly advise calling DCF prior to making any changes.

Can Florida Medicaid be Used Out of State?

Many people assume that Medicaid benefits from one state can be used when traveling to another state.  Although Medicaid is managed with oversight from the federal government, each state is given flexibility to set its own eligibility and coverage requirements.

Unfortunately, in the vast majority of cases, Florida Medicaid will not cover health services provided in another state.  At best, Florida Medicaid will only cover out-of-state emergency room visits to stabilize an emergency situation.  All other non-emergency costs will not be covered, and costs will be out-of-pocket for a beneficiary.  When in doubt, it is best to contact Florida Medicaid first to determine if a service will be covered elsewhere.

Florida Medicaid beneficiaries who will be moving to another state, either temporarily or permanently, must apply for Medicaid in the new state where they will reside.  Federal law prevents a person from being enrolled in Medicaid in two states at the same time, so a beneficiary will need to cancel their Medicaid coverage in Florida before applying for coverage in a new state.  The good news is that retroactive coverage does exist, and beneficiaries should not be concerned about a gap in coverage when seeking a new plan in a new state.  The only concern is that each state has its own set of eligibility criteria, and what qualifies in Florida may not qualify in other states.

How Do I Contact Medicaid in Florida?

Florida Medicaid Customer Call Center

8 am to 5pm, Monday through Friday

1-866-762-2237

Florida Relay 711 or
TTY 1-800-955-8771

FAX: 1-866-886-4342

Florida Medicare Mailing Address

ACCESS Central Mail Center
P.O. Box 1770
Ocala, FL 34478-1770

ACCESS Florida Medicaid website

http://www.myflorida.com/accessflorida/

ACCESS Service Center Locations

The state maintains Service Centers throughout Florida.  To find the Service Center nearest to you, go here.

Florida Department of Children and Families

The Florida Department of Children and Families also maintains regional facilities for your convenience.

Central Region – Brevard, Citrus, Hardee, Hernando, Highlands, Lake, Marion, Orange, Osceola, Polk, Seminole, Sumter

Northeast Region – Alachua, Baker, Bradford, Clay, Columbia, Dixie, Duval, Flagler, Gilchrist, Hamilton, Lafayette, Levy, Madison, Nassau, Putnam, St. Johns, Suwannee, Taylor, Union, Volusia

Northwest Region – Bay, Calhoun, Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Okaloosa, Santa Rosa, Wakulla, Walton, Washington

Southeast Region – Broward, Indian River, Martin, Okeechobee, Palm Beach, St. Lucie

Southern Region – Dade, Monroe

SunCoast Region – Charlotte, Collier, DeSoto, Glades, Hendry, Hillsborough, Lee, Manatee, Pasco, Pinellas, Sarasota

The Agency for Health Care Administration also provides information several state health care related topics.  This includes things such as Civil Rights Compliance, Complaint Investigations of Facilities, Financial Statements for the ACHA, Hospital Financial Data, Recipient and Provider Assistance, and many more.  To access a complete list of information topics, go here.