Medically Needy Program

What is the Medically Needy Program?

The Medically Needy program can help pay for Medicaid-covered services. Individuals enrolled in the Medically Needy Program have income or assets that exceed the limits for regular Medicaid. A certain amount of medical bills must be incurred each month before Medicaid is approved. This is your “share of cost.”

What is “Share of Cost”?

Your “share of cost” is the amount of medical bills that you must have before Medicaid can pay any of your other incurred medical bills for you. Your “share of cost” works like a deductible on a health insurance policy. Your “share of cost” is based on your family’s monthly income. Your “share of cost” may be “estimated” based on your statement of your family’s monthly income. You must incur medical expenses equal to the amount of your “share of cost” each month before you can become eligible for Medicaid for the rest of the month.

How Does It Work?

Each month certain medical expenses, called “allowable medical expenses” which you owe or have paid during the month are counted toward your “share of cost”.  When your allowable medical expenses are equal to your “share of cost” you may be eligible for Medicaid for the rest of that month. If your “share of cost” was estimated, your family’s income must be verified before Medicaid can pay any bills.

Before using any medical services, you must be sure the provider is willing to accept Medicaid as payment.

The following example is how “share of cost” works.  If your “share of cost” is $800 and you go to the hospital on May 10th and receive a bill for $1000, you have met the “share of cost” and are Medicaid eligible from May 10th through May 31st.

If the bill from May 10th is a Medicaid covered service received from a Medicaid provider, Medicaid will pay the bill. This is only an example.

What are Allowable Expenses?

Allowable medical expenses are bills that:

  • Are unpaid and still owed and have not been used in an earlier month to meet your “share of cost”.
  • Are paid during the current month.
  • Have not been paid for you or will not be paid by health insurance, another person or any other source.

There are two kinds of allowable medical expenses:

  • Health insurance costs and
  • Medical service costs.

Health insurance costs include:

  • Medicare premiums.
  • Other health insurance premiums, including HMO and prepaid plan premiums.
  • Co-insurance payments.

Medical service costs include:

  • Medical goods and services prescribed by a doctor.
  • Transportation by ambulance, bus or taxi to get medical care.

What Medical Expenses Cannot Be Used To Meet your “Share of Cost”?

  • Premiums for insurance policies that pay you money when you are in the hospital or when the payment is not intended to pay for medical expenses.
  • First aid supplies and medicine chest supplies such as adhesive bandages, alcohol, cold remedies, etc.

What Do I Need To Do?

You need to provide proof of your medical expenses to an ACCESS Florida office.
You or your Medicaid provider can do this by fax, mail, or in person.
Please include:

  • the amount of the expense;
  • the date the expense was incurred; and
  • the date and amount of any payments that you have made for the expense.

There are several kinds of proof you can provide, such as:

  • medical bills you have received,
  • receipts for paid medical bills and
  • cancelled checks for paid medical bills.

What Will I Get With Medicaid?

Medicaid covers a wide range of medical services, including hospitalization, doctor visits, prescription drugs and medical transportation, to name a few, that are provided by enrolled Medicaid providers.  There are limitations and exclusions on some of these covered services.
The Agency for Health Care Administration (AHCA) can give you more information on Medicaid covered services and enrolled providers for those services. Contact the local AHCA Area Office for your county listed on the back cover or visit their website at www.fdhc.state.fl.us.

What If I Have Questions About My “Share of Cost”? If you have questions about how “share of cost” works, what expenses count, or what proof is needed, contact the Department of Children and Families at: 1-866-76-ACCESS or 1-866-762-2237, 1-800-955-8771 (TTY).
We will consider your eligibility for assistance   without regard to race, color, sex, age, disability, religion, national origin, political belief or marital status

You can print the Medically Needy Program Brochure