Miriam Harmatz | Co-Executive Director, Florida Health Justice Project
Margaret Kosyk | Staff Attorney, Coast to Coast Legal Aid of South Florida
Jazmine Janine Dykes | J.D.
We want to thank those who contributed, including the National Health Law Program (NHeLP). In addition to preparing The Advocates Guide to the Medicaid Program, a voluminous and essential resource for any health lawyer, Jane Perkins and Sarah Somers also provided a template for individual state guides. And Sarah not only generously shared her Advocate’s Guide to the North Carolina’s Medicaid Program (much of which appears in this document), she took time to review and edit this Guide.
We also want to thank Margaret Kosyk and Jazmine-Janine Dykes. Thanks are also due to Anne Swerlick, Florida Policy Institute, who has encyclopedic knowledge of Florida’s Medicaid Program, and Laurie Yadoff, Coast to Coast Legal Aid of South Florida, an expert in Florida's disability/Medicaid application process. They both took the time to answer questions and locate policies that are not easily available on line.
Executive Director, Florida Justice Technology Center
Co-Director, Florida Health Justice Project
April 23, 2018
Medicaid is a complex and frequently changing federal-state insurance program that covers medical expenses for eligible beneficiaries. Each state implements its own Medicaid plan in compliance with the federal Medicaid statute and regulations. While the federal statute and regulations prescribe the basic rules of the Medicaid program, states have significant flexibility and each state’s Medicaid program is unique.
This Guide provides an overview of the authority governing Florida’s Medicaid program and addresses basic questions asked by advocates, applicants and beneficiaries including:
When the Medicaid program was passed in 1965, coverage was limited to low-‐ income individuals who qualified for either the “disability” related coverage (aged, blind, or disabled) or family related coverage (children, pregnant women, parents).
Half a century later, the Affordable Care Act eliminated this requirement of a “categorical connection.” The overarching goal of the ACA was to establish a path to affordable coverage for all Americans (and eligible immigrants). In addition to providing subsidies to lower the cost of coverage for individuals and families with household income between 100% and 400% of the federal poverty level,2 it also required states to expand their Medicaid program to provide coverage for low-‐ income adults under 138% of FPL.3
Shortly after passage of the ACA, Florida and other states sued the federal government alleging, inter alia, that this “Medicaid expansion” was unconstitutional. In National Federation of Independent Business v. Sebelius (NFIB), the Court upheld the ACA’s individual mandate as constitutional. The Court also ruled, however, that requiring states to expand their Medicaid programs to cover low income adults who did not meet a categorical connection was “overly coercive.”4 The Court’s decision meant that each state would decide whether or not to extend coverage to this group. As of April 2018, Florida is one of 19 states that has refused federal funding for coverage of the Medicaid expansion population.
SOURCES OF FEDERAL AND STATE AUTHORITY
Medicaid Administration and Funding
At the federal level, Medicaid is administered by the Centers for Medicare and Medicaid Services (CMS) within the U.S. Department of Health and Human Services (USDHHS). CMS divides the states into ten different regions, with a regional office for each, and Florida is in Region IV.6
Federal law requires each state to administer its Medicaid program through a single state agency. The designated state agency in Florida is the Agency for Health Care Administration (AHCA).
One of the most significant aspects of the Medicaid program is the financing structure by which the federal government, pursuant to a formula based on the state’s poverty level, guarantees federal “matching funds” for the state’s expenditures. In Florida, the guaranteed funding formula means that for every $1 spent on Medicaid covered services for eligible enrollees, the federal government provides approximately $.627
Had Florida expanded Medicaid under the ACA, the federal government would have paid 100% for the first three years after the ACA was implemented (2014-‐17). If/when Florida chooses to extend coverage to those low-income adults eligible for Medicaid under the ACA, the federal matching rate for the cost of covering this population will be no less than 90% as of 2020 and thereafter.8
Under federal law, states must cover specified mandatory coverage groups, and states may cover additional categories who meet eligibility requirements.
Eligibility requirements include financial (income and resources) as well as technical requirements, e.g. citizenship and residency. Different financial eligibility limits and methodologies apply depending on whether the individual’s categorical connection to Medicaid is disability or family Related.
Eligible individuals who qualify for coverage under any mandatory or optional category are known as the “categorically needy.”9 States may also cover individuals who otherwise fit into a Medicaid category but whose income or resources exceed the limit. This coverage group, which Florida has adopted, is referred to as “Medically Needy."10
Florida's mandatory and optional coverage groups are set forth below.
MANDATORY COVERAGE GROUPS11
Family Related Medicaid Eligibility
Florida's Family Related Medicaid Groups include the following:
Continuous Eligibility for Children
Under federal law, states have the option of providing continuous eligibility for children even if the family income exceeds allowable limits over the course of the eligibility period.
Pursuant to this option, Florida covers children up to age 19 for 6 months and children up to age 5 for 12 months, “regardless of changes in circumstances.”17
Modified Adjusted Gross Income (MAGI)
Under the ACA, income eligibility for each Family Related Medicaid group is based on the modified adjusted gross income (MAGI).18 The National Health Law Program has provided a comprehensive guide to understanding MAGI.19
Generally, MAGI includes the adjusted gross income plus certain exclusions such as any tax-‐exempt Social Security, interest and foreign income. 20
MAGI does include:21
SSI Related Medicaid Eligibility
Florida’s SSI related Medicaid coverage groups include the following: 26
To be eligible for Medicaid coverage an individual must be a U.S. citizen or a “qualified alien.”35 Certain qualified aliens are prohibited from receiving Medicaid for the first five years after they immigrate.36 There is no coverage for unqualified immigrants except through Emergency Medical Assistance to Aliens (EMA).37
Qualified aliens not subject to five-‐year wait include: refugees; asylees; individuals who are veterans or on active duty military; spouses and children of veterans or active military personnel; American Indians born in Canada Cuban or Haitian entrants; Amerasian immigrants trafficking victims; and lawful permanent residents admitted before August 22, 1996 and residing continually in the U.S. since admission.38
Qualified aliens subject to five-‐year wait period include: adult lawful permanent residents admitted after August 22, 1996 (ineligible from the date of entry or obtaining qualified status, whichever is later); parolees; conditional entrants; and battered aliens.39
Significantly, in 2016 Florida eliminated the 5-year bar through the Immigrant Children’s Health Improvement Act (ICHIA) option for children for Medicaid and CHIP (Florida KidCare).40
Medicaid eligibility is dependent on state residency.41 An individual is a resident of Florida if she resides in in the state with the intent to remain. Residency does not depend on the duration of the stay, and individuals are not required to have a permanent or fixed address to establish state residence. However, the requirement will not be satisfied if the stay is for a temporary purpose or there is intent to return to another state.42
If the individual is living in the State for employment purposes without the intent to remain, she/ he meets the residency requirements if: 1) the individual or caretaker relative does not receive assistance from another state; and 2) the individual or caretaker relative came to the state with a job or is seeking employment.43
In October 2017, DCF issued a policy transmittal regarding the residency requirements for evacuees from Puerto Rico due to Hurricane Maria.44
Other Eligibility Requirements
In addition to being within a mandatory or optional coverage group and meeting financial, citizenship immigration and residency requirements, with certain exceptions, applicants must also:
Under federal Medicaid law, costs incurred during the three months prior to the month of application can be reimbursed if: 1) they are covered under the Florida Medicaid plan; and 2) the beneficiary would have been eligible for Medicaid at the time the expenses are incurred.48
The 2018 Legislature, however directed AHCA to seek federal approval to change this provision for non-pregnant adults. For those individuals, costs would only be covered from the first day of the month of application.49
The initial comment period to AHCA ended April 19, 2018. This Guide will be updated following the full comment period and a decision by CMS.
SECTION 3: APPLICATIONS AND DETERMINATIONS
If a person fulfills the state’s requirements for eligibility, she/he is entitled to Medicaid. States may not place limits on enrollment or place applicants on waiting lists (except for home and community based waivers). In other words, Medicaid is an entitlement. 50
In Florida, the Department of Children and Families determines eligibility,51 and there should be “no wrong door” for applicants.
Applying for Family-Related Medicaid
Because there is “no wrong door,” applications can be made in person with a DCF community partner, at a DCF community service center, by paper application through the mail or by fax, online at the DCF ACCESS Florida website, http://www.myflorida.com/accessflorida, or online at the Health Insurance Marketplace website, www.healthcare.gov 52
As a practical matter, applying online to DCF’s ACCESS website above is generally recommended as the quickest method. DCF has 45 days to process the application and issue an eligibility determination.53
Applying for Disability-Related Medicaid
Medicaid recipients are subject to a periodic review of their eligibly. Redetermination requires re-verification of certain eligibility factors.64
graph text here.
Ex Parte Determinations
Under Medicaid law, AHCA must continue to provide Medicaid to beneficiary’s unless/until the individual is found to be ineligible. In other words, DCF must on its own (or “ex parte”) determine whether a Medicaid beneficiary who is no longer eligible under one coverage group is eligible under a different coverage group, and coverage must be continued during this process. 68
· An increase in income or assets causes ineligibility;
· An individual’s SSI is and cancelled.
Notice and Hearing Rights
General Principles of Medicaid Services
Another major governing principle is that if provider accepts Medicaid, they have to accept Medicaid as payment in full. With the exception of allowable cost sharing authorized under federal law and the state plan, providers cannot bill patients for services.85
Early Periodic Screening Diagnosis and Treatment
Medical screens must be provided according to a “periodicity schedule.” 89
Vision, Hearing, and Dental Services
Interperiodic, or "As Needed" Screens
The "T" in EPSDT
Informing Eligible Families About EPSDT
SECTION 5: MANAGED CARE
As noted, most Medicaid recipients are required to receive their covered services through a managed care health plan.98 The voluntary enrollment population for MMA program, as well as the population excluded from the entire SMMC managed care program, are bulleted below.
Who may (but need not" enroll in MMA?99
If an individual is determined to be eligible for Medicaid and a health plan has not been selected during the application process, they will be enrolled into a plan through auto-assignment.
Through this process, also referred to as “ Express Enrollment, ” health plan enrollment will be effective the same day that the recipient’s eligibility application is approved.
Managed Care Services
An important goal of the MMA program and the 2016 federal Medicaid managed care regulations is ensuring that plans have sufficiently robust networks so that enrollees can access services in a timely manner. The legislation implementing Florida’s MMA program specifically mandates that:
Changing Plans / Disenrolling
Recipients may request disenrollment at any time via written or oral request to AHCA. Disenrollment is permitted as follows:
The following reasons constitute good cause for disenrollment:107
Filing a Complaint
Enrollees who are having trouble accessing services or who are encountering other problems with their SMMC services can file an official complaint.
Grievances, Appeals, and Fair Hearings
What is the difference between a grievance and an appeal?
Each plan is required to have a grievance and appeal process that complies with the federal Medicaid managed care regulations. 108 The major difference between a grievance and an appeal is that an appeal should be filed when there is an “adverse benefit determination (ABD),” while a grievance would be filed if the enrollee is unhappy with the plan. For example, an enrollee could file a grievance if he or she was treated rudely.109
What is the Adverse Benefit Determination (ABD)?
Adverse benefit determinations include:
The notice must include the following information:
· requests for production of documents,
· requests for admission,
· depositions. 125
Appendix 1: Managed Care Assistance Program Minimum Covered Services
Appendix 2: Filing and Resolution Time Frames
91 K.G. ex rel Garrido v. Dudek, 839 F. Supp. 2d 1254, 1275 (S.D. Fla. 2013)(In granting preliminary injunction, court rejected Defendant’s claim that plaintiff cannot show a substantial likelihood of success on the merits because he has failed to allege that his autism was discovered through an "EPSDT" screening, noting that “inter-‐periodic screens include any visit to a physician (including family-initiated visits) to determine if the child has a condition requiring further assessment, diagnosis or treatment.”
95 42 U.S.C. § 1396a(a)(43).