Current through Reg. 50, No. 187; September 24, 2024
(1) Date of
Eligibility. Eligibility for Medicaid begins the first day of a month if an
individual was eligible any time during the month, except as provided below:
(a) Presumptive Eligibility for Pregnant
Women (PEPW). The period of presumptive eligibility for pregnant women begins
when a Qualified Designated provider, as defined in Rule
65A-1.701, F.A.C., determines
that the woman is eligible. Presumptive eligibility ends when a determination
for full Medicaid is made (approved or denied), or on the last day of the month
following the month the presumptive eligibility determination is made if an
application for ongoing Medicaid coverage is not filed.
(b) Presumptive Eligibility by Hospitals. The
period of presumptive eligibility by hospitals begins on the date the
determination is made. Presumptive eligibility ends when a determination for
full Medicaid is made (approved or denied) or on the last day of the month
following the month the presumptive eligibility determination is made if an
application for ongoing Medicaid coverage is not filed.
(c) Presumptive Eligiblity for Newborn (PEN).
Eligibilty for a presumptively eligible newborn begins on the date of birth and
continues for one year unless one of the following occurs:
1. The child leaves the state,
2. The child dies, or
3. There is a request for voluntary
closure.
(d) Medically
Needy Program. Enrollment under the Medically Needy Program begins on the first
day of the month the individual satisfies the non-financial and resource
eligibility criteria, if applicable, but not earlier than the third month prior
to the month of application. Medicaid Eligibilty under the Medically Needy
Program begins on the date their incurred allowable medical expenses equal the
amount of their share of cost (SOC).
(e) Emergency Medicaid for Aliens (EMA).
Coverage for individuals eligible for EMA begins the first day of a covered
emergency and ends the day following the last day of the emergency medical
situation. A Medicaid renewal date of 12 months will be assigned. Subsequent
medical emergencies require documentation, but the individual will not have to
file a new application and the Department will not make a new eligibility
determination during this 12 month period. Changes in the SFU circumstances
will continue to affect eligibility.
(2) Processing Medicaid Applications for
Supplemental Security Income (SSI) Denials.
(a) The Department will use data obtained
from the Social Security Administration's (SSA) State Data Exchange (SDX) to
identify individuals who have been denied SSI benefits.
(b) The Department will identify the
individuals for whom the Department does not have an open Medicaid case or a
pending Medicaid application at the time the SDX data is received. The
Department will explore eligibilty under another coverage group with
information based on available information receieved from the SDX data. If
additional information is required to make a determination, these individuals
or their SSA payee will be notified in writing to contact the Department within
30 calendar days. Failure to do so without good cause, will result in the
issuance of a written notice of Medicaid denial for failure to follow through
in determining eligibility.
(c)
Good cause means illness of the individual or a family member, an accident
involving the individual or a family member, hospitalization of the individual
or a family member, death of the individual or a family member, natural
disasters in a relevant geographical area, being away from home or the
unexpected closure of a Department's office.
(d) Those individuals whom the Department
identifies as having an open Medicaid case or a pending Medicaid application at
the time the SDX data is reviewed will not be required to contact the
Department, unless additional information is needed to complete the eligibility
process.
(e) A determination of
eligibility will be completed on the individuals who respond to written notice
to contact the Department.
(3) Ex Parte Process.
(a) When a recipient's eligibility for
Medicaid ends under one coverage group, the Department must evaluate their
eligibility, using available information, under any other Medicaid coverage
group before terminating Medicaid coverage. If additional information is
required to make an ex parte determination it can be requested from the
recipient. There is no requirement for the individual to contact the Department
or file an application to initiate the ex parte review for continued Medicaid
eligibility.
(b) All individuals
who lose Medicaid eligibility under one coverage group will continue to receive
Medicaid under that coverage group until the ex parte Medicaid renewal process
is complete.
(c) Qualified
individuals losing eligibility due to income that was calculated based on the
Modified Adjusted Gross Income (MAGI) budgeting methodology will be transferred
to the Children's Health Insurance Program (CHIP) or the Federally Facilitated
Marketplace (FFM) for a determination of eligibility.
(4) Requirement to File for Other Benefits.
As a condition of eligibility for Medicaid, the Department must require an
individual to take all necessary steps to obtain any annuities, pensions,
retirement, and disabilty benefits to which they are entitled, unless they can
show good cause, as defined in paragraph (2)(c) of this rule, for not doing so.
Annuities, pensions, retirement and disability benefits include, but are not
limited to, veterans' compensation and pensions, OASDI benefits, railroad
retirement benefits, and unemployment compensation. After the Department
notifies an individual that they must apply for the other benefit(s), if the
individual fails to do so, they are not eligible for Medicaid.
(5) Child Support Enforcement Cooperation
(CSE). For the purpose of establishing Medicaid eligibility, a pregnant woman
is not required to cooperate with CSE as a condition of eligibility.
Cooperation with CSE is also not required in Medicaid cases where benefits are
only requested for a child.
(6)
Re-evaluating Medicaid Adverse Actions for Individuals who do not Request a
Hearing. The Department shall re-evaluate any adverse Medicaid determination
upon a showing of good cause by the individual that the Department's previous
determination was incorrect. This provision applies only when benefits were
terminated or denied in error or the amount of a share of cost or patient
responsibility was determined incorrectly. A re-evaluation must be requested
within 12 months from the effective date of the notice of adverse action.
(a) Good cause for establishing the previous
determination was incorrect consists of any of the following:
1. Mathematical Error - The Department made a
mechanical, computer or human error in its mathematical computations of
resources or income requirements for Medicaid eligibility.
2. Records Error - The Department made an
error in a Medicaid determination which caused an incorrect decision. For
example, there is evidence showing that the individual's resources satisfied
Florida's standard of eligibility but the application was denied on the basis
of excess resources.
3. New and
Material Evidence - The Department's determination was correct when made but
new and material evidence that the Department did not previously consider
establishes that a different decision should be made.
(b) Good cause for not requesting a hearing
within the prescribed 90 day time period exists when the failure was due to
circumstances beyond the individual's control or due to an unexpected closure
of Department offices.
(c) Failure
of the individual to provide information required by the Department to
accurately determine eligibility for Medicaid where the failure was beyond the
individual's control constitutes good cause for re-evaluation. However, if the
individual fails to cooperate with the Department in establishing eligibility,
good cause for re-evaluation does not exist.
(d) The Economic Self Sufficiency Specialist
(ESSS) is responsible for the initial determination of whether good cause for
re-evaluation exists. The decision must be reviewed by the ESSS's supervisor.
If both the ESSS and the ESSS's supervisor determine that good cause does not
exist, the next level administrator, in consultation with the Regional Program
Administrator, must review the decision.
1. If
a determination is made by the Regional Program Administrator that good cause
does not exist, the individual will be notified of the decision and of the
right to to request a fair hearing.
2. If a determination is made by the Regional
Program Administrator that good cause exists and the Department discovers that
an error was made in the eligibility determination, benefits must be provided
retroactively as follows:
a. If an application
was denied, benefits will be awarded back to the date of application, provided
all other eligibility requirements are met.
b. If an ongoing case was terminated,
benefits will be awarded back to the effective date of the termination,
provided all other eligibility requirements are met.
3. If a determination is made by the Regional
Program Administrator that good cause exists and the original determination is
determined to be correct, the individual will be notified of the Department's
decision. The individual has 90 calendar days from the date of notice of
disposition to request a hearing. If at the end of 90 calendar days a hearing
is not requested, the Department's decision is final and binding upon the
individual.
(7)
Assignment of Rights to Benefits. Each individual applying for or receiving
Medicaid must cooperate in securing the receipt of medical support and payments
from third parties that are otherwise due to the individual, unless good cause
exists for not cooperating. Good cause exists when the individual previously
applied for and was denied third party benefits or medical support, and the
reason for denial has not changed.
(8) Retroactive Medicaid. Retroactive
Medicaid is based on an approved, denied, or pending application for ongoing
Medicaid benefits. For applications submitted on or after February 1, 2019,
retroactive coverage only applies to applications for children under age 21 and
pregnant women, including their postpartum period.
(a) Retroactive Medicaid eligibility is not
effective before the third month prior to the month of application. The
individual must meet all Medicaid eligibility requirements during the
retroactive months. A request for retroactive Medicaid can be made for a
deceased individual by a designated representative or caretaker relative, by
filing a medical assistance application. However, Qualified Medicare
Beneficiaries (QMB's) are not eligible for retroactive Medicaid benefits as
indicated in Title XIX of the Social-Security Act §1902(e)(8).
(b) SSI Cash Assistance Recipients. Upon SSI
approval, all SSI recipients receive a system-generated notice of potential
entitlement for retroactive Medicaid benefits and a reply card to be returned
to the Department if the SSI recipient is interested in receiving retroactive
Medicaid benefits. If the SSI recipient or their designated representative or
caretaker relative contacts the Department, the Department will proceed with an
eligibility determination.
(9) Re-Enrollment. In order for an individual
or family to be eligible for re-enrollment in the Medically Needy program, they
must:
(a) Continue to satisfy the resource
criteria, if applicable;
(b)
Continue to satisfy all non-financial eligibility criteria; and
(c) Provide verifications as needed. The
re-enrollment period may exceed 12 months when there is a delay in the
Department's processing of the re-enrollment.
(10) Limits of Coverage.
(a) Qualified Medicare Beneficiary (QMB).
Under QMB coverage, individuals are eligible for Medicare cost-sharing
benefits, including payment of Medicare premiums.
(b) Specified Low-Income Medicare Beneficiary
(SLMB). Under SLMB coverage, individuals are eligible for payment of the Part B
Medicare premium. If eligible, AHCA will pay the premium for up to three months
retroactive to the month of application.
(c) Working Disabled (WD). Under WD coverage,
individuals are eligible for payment of their Medicare Part A
premium.
(d) Qualifying Individuals
1 (QI1). Under QI1 coverage, individuals are eligible for payment of their
Medicare Part B premium. (This is coverage for individuals who would be
eligible for QMB or SLMB coverage except that their income exceeds the limits
for those programs.) If eligible, AHCA will pay the premium for up to three
months retroactive to the month of application.
(11) Determining Share of Cost (SOC). The SOC
is determined by deducting the appropriate Medically Needy Income Level from
the individual's or family's income.
(12) Eligibility of SSI Cash Assistance
Recipients. Eligible SSI recipients who are residents of Florida are
automatically eligible for Medicaid pursuant to 42 C.F.R. §
435.120.
(13) Trusts.
(a) The Department applies trust provisions
set forth in §1902 of the Social Security Act.
(b) Funds transferred into a trust or other
similar device established other than by a will prior to October 1, 1993, by
the individual, a spouse, or a legal representative are available resources if
the trust is revocable or if the trustee has any discretion over the
distribution of the principal. Such funds are a transfer of a resource or
income, if the trust is irrevocable and the trustee does not have discretion
over distribution of the corpus, or if the individual is not the beneficiary.
No penalty can be imposed when the transfer occurs beyond the 60 month
look-back period. Any disbursements which can be made from the trust to the
individual or to someone else on the individual's behalf shall be considered
available income to the individual. Any language which limits the authority of
a trustee to distribute funds from a trust, if such distribution would
disqualify an individual from participation in government programs, including
Medicaid, shall be disregarded.
(c)
Funds transferred into a trust, other than a trust specified in 42 U.S.C. §
1396p(d)(4), by a person or entity specified in 42 U.S.C. §
1396p(d)(2) on or after October 1, 1993, shall be considered available
resources or income to the individual in accordance with 42 U.S.C. §
1396p(d)(3) if there are any circumstances under which disbursement of
funds from the trust could be made to the individual or to someone else for the
benefit of the individual. If no disbursement can be made to the individual or
to someone else on behalf of the individual, the establishment of the trust
shall be considered a transfer of resources or income.
(d) The trustee of a qualified income trust,
qualified disabled trust, or a pooled trust shall provide quarterly statements
to the Department which identify all deposits to and disbursements from the
trust for each month during the eligibility period.
(e) Undue Hardship. A period of ineligibility
shall not be imposed if the Department determines that the denial of
eligibility based on counting funds in an irrevocable trust according to
provisions in paragraph
65A-1.702(13)(b),
F.A.C., would create an undue hardship on the individual. Undue hardship exists
when application of a trust policy would deprive an individual of food,
clothing, shelter or medical care such that their life or health would be
endangered. This can be caused by legal restrictions or by illegal actions of a
trustee. All efforts by the individual, or their legal spouse or
representative, to access the resources or income must be exhausted before this
exception applies.
(14)
Statewide Inpatient Psychiatric Program (SIPP). SIPP is for Medicaid eligible
children under the age of 21 who require a residential level of care for
treatment of a serious emotional disturbance. Those who are Medically Needy and
those who are Medicare recipients are excluded from this program. Services must
be received from a designated SIPP provider selected by the Agency for Health
Care Administration (AHCA). SIPP providers must be licensed as a hospital or
residential treatment center for children and adolescents by AHCA. This program
provides an exception to provisions that residents of an institution for mental
disease (IMD) are not eligible for Medicaid.
Rulemaking Authority
409.919 FS. Law Implemented
409.903,
409.904,
409.919
FS.
New 10-8-97, Amended 4-22-98, 2-15-01, 9-24-01, 11-23-04,
5-31-06, 8-10-06, 3-25-20.
