Understanding Medicaid Programs

Medicaid is a federal program administered by each state that provides assistance to low-income individuals who meet the eligibility criteria set by that state. In Florida eligibility is based on age or disability according to Social Security Standards and on income and asset limits. Financial eligibility changes annually and varies by program. Apply on the internet at http://www.myflorida.com/accessflorida/.

Full Medicaid benefits provide a variety of health services, but they must be obtained from providers who are certified to accept payment from Medicaid. Individuals who have Medicare may also have Medicaid, but Medicaid will only pay for services after Medicare has paid. For prescription drug coverage, individuals with Medicare must enroll in the Medicare Part D Prescription Drug Plan.

Programs that provide full Medicaid benefits include:

Supplemental Security Income (SSI) recipients – SSI is administered by the Social Security Administration and provides financial assistance to needy persons age 65 and over and to needy blind and disabled persons. Individuals who meet receive SSI through Social Security are automatically eligible to receive Medicaid in Florida.

MEDS for Aged and Disabled (MEDS- AD) – This program changed 1/1/2006 and now serves a limited group of those age 65+ or disabled who meet income and asset criteria and do not have Medicare A or B. It also serves clients who are in other Medicaid programs.

Institutional Care Program (ICP) – ICP helps people age 65+ or disabled and in nursing facilities pay for cost of their care plus provides general medical coverage. Must meet level-of-care as determined by the Department of Elder Affairs CARES Unit. There may be financial responsibility for the patient and eligibility may involve an Income Trust.

Statewide Medicaid Managed Care Long-term Care Program – In 2011, the Florida Legislature created this new program.  Because of this program, the Agency for Health Care Administration (AHCA) and Department of Elder Affairs changed how some individuals receive long-term care from the Florida Medicaid Program.  There are two different programs that make up the Statewide Medicaid Managed Care:  The Long-Term Care (LTC) Managed Care Program and the Managed Medical Assistance (MMA) Program.  Medicaid recipients who qualify and become enrolled in SMMC LTC will receive long-term care services from a long-term care managed care plan.  Click here for additional information.

Hospice – Provides Medicaid services for terminally ill persons. Apply through a local Hospice. Financial eligibility is the same at the Institutional Care Program (ICP).

Developmental Services Waiver Program (DS Waiver) – Prevents institutionalization by allowing individuals age 3 and over with developmental disabilities to remain at home in the community. Financial eligibility is the same at the Institutional Care Program (ICP). Funding for this program is limited and not everyone who applies will receive services. Contact the Agency for Persons with Disabilities for information.

Project AIDS Care Waiver Program (PAC Waiver) – Provides home and community based services for individuals who are age 65+ or disabled and who have a diagnosis of AIDS. Financial eligibility is the same at the Institutional Care Program (ICP).  Funding for this program is limited and not everyone who applies will receive services.

Cystic Fibrosis Waiver Program ( CF Waiver) – Provides home and community-based services for individuals age 18 and over who are diagnosed with cystic fibrosis, require hospitalization but could remain at home if provided special services. Financial eligibility is the same at the Institutional Care Program (ICP). Funding for this program is limited and not everyone who applies will receive services.

Medicaid Programs that have limited Medicaid benefits include:

Medically Needy – Provides Medicaid for persons with high medical bills but who are not eligible for Medicaid because their income or assets are too high. Those enrolled in this program must incur a certain amount of medical bills each month, which is known as “share of cost”. This amount is based on income and household size. Once the share of cost is reached, the DCF can approve full Medicaid benefits for the remainder of that month only. Medicaid does not cover the costs of prescription drugs for Medicare recipients who must now use the Medicare Part D prescription coverage.

Qualified Medicare Beneficiary (QMB) – Individuals who qualify for QMB are eligible to have Medicaid pay for Medicare Premiums for Parts A and B, Medicare deductibles, and Medicare coinsurance within the prescribed limits. This is the only Medicaid benefit.

Special Low Income Medicare Beneficiary (SLMB) – Individuals who are eligible for SLMB are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. This is the only Medicaid benefit.

Qualified Individuals (QI-1) – Individuals who are eligible for QI1are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. The income limits are higher than SLMB and payment is only guaranteed through the end of the year the application was made. This is the only Medicaid benefit.

All full Medicaid recipients and QMB, SLMB and QI-1 beneficiaries are automatically entitled to Extra Help with Medicare Prescription Drug Plan costs. This is also known as Low Income Subsidy (LIS) and it pays all or most of the annual deductible, provides coverage during the gap period, and pays the monthly premium up to a base amount. Co-pays are the responsibility of the individual.

Medicaid has complex programs. The eligibility requirements mentioned above are meant to provide basic information only and do not include detailed information that should be obtained through DCF. The Fact Sheet is for information purposes and is not a legally binding document.