59G-1.058. Eligibility

(1) Purpose. This rule specifies recipient eligibility requirements for Florida Medicaid covered services and applies to all providers rendering Florida Medicaid covered services to recipients.

(2) Eligibility Determination. The Department of Children and Families (DCF) and the Social Security Administration (SSA) determine recipient eligibility for Florida Medicaid in accordance with Section 409.902, F.S., and Rule Chapter 65A-1, Florida Administrative Code (F.A.C.).

(a) Eligibility Determined by Qualified Designated Providers. Qualified designated providers determine presumptive eligibility for pregnant women (PEPW) in accordance with Rule Chapter 65A-1, F.A.C.

(b) Eligibility Determined by Qualified Hospitals.

1. Qualified hospitals enrolled in Florida Medicaid may make presumptive eligibility determinations for the following:

a. Pregnant women.

b. Infants and children under the age of 19 years.

c. Parents and other caretakers or relatives.

d. Former foster care children.

2. The presumptive period begins on the date the determination is made and ends on the earlier of the following:

a. The last day of the month following the month in which the determination of presumptive eligibility is made.

b. The date DCF makes a Florida Medicaid eligibility determination.

(3) Newborn Presumptive Eligibility. A newborn is deemed eligible for full Florida Medicaid covered services when the mother is eligible for Florida Medicaid on the date of the child’s birth, unless the mother is eligible under the PEPW category.

(a) A pregnant recipient may obtain a Florida Medicaid identification (ID) number and Florida Medicaid ID card for her unborn child. The cards are issued as “baby of” plus the mother’s name, and assigned a card control number that providers use to obtain the baby’s Medicaid ID number. The baby’s Florida Medicaid ID number will not be active until after the baby is born.

(b) Providers may request a Florida Medicaid ID number assignment for a newborn via a Medical Assistance Referral Form, CF-ES 2039, April 2003, incorporated by reference in Rule 65A-1.400, F.A.C., and available on the DCF Website at https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx.

(c) Providers may activate a newborn’s Florida Medicaid ID number by submitting a completed Unborn Activation Form, AHCA Form 5240-006, February 2017, incorporated by reference in Rule 59G-1.045, F.A.C., to the Florida Medicaid fiscal agent.

(4) Proof of Eligibility. Providers must verify recipient eligibility prior to rendering services.

(5) Recipient Does Not Have an ID Card. Providers may verify eligibility and render services if the recipient does not have an ID card.

(6) Card Not Proof of Eligibility. Possession of a Florida Medicaid ID card does not constitute proof of eligibility.

(7) Eligibility Program Codes (also known as Aid Categories). Florida Medicaid eligibility program codes indicate benefit coverage and limitations, as follows:

FLORIDA MEDICAID ELIGIBILITY CODES ON THE FLORIDA MEDICAID MANAGEMENT INFORMATION SYSTEM RECIPIENT SUBSYSTEM
Code	Description	Coverage
5007	Pharmaceutical Expense Program	Provides assistance with Medicare Part B coinsurance for persons not eligible for Florida Medicaid or Qualified Medicare Beneficiaries (QMB), who were diagnosed with cancer or received an organ transplant and were receiving drugs to treat these conditions in December 2005 under the Medically Needy program, who were and continue to be, eligible for Medicare. This is not a Florida Medicaid service; it is funded in full by general revenue.
MA I	Former Foster Care Children Up to Age 26	Full Medicaid, except institutional care in skilled nursing facility or swing bed, intermediate care facility for individuals with intellectual disabilities (ICF/IID), state mental health hospital, or home and community-based (HCBS) waiver services.                                         Full Medicaid, except institutional care in skilled nursing facility or swing bed, ICF/IID, state mental health hospital, or HCBS waiver services.
MA R	Parents and Caretakers
MB C	Mary Brogan Breast and Cervical Cancer Program
MCFE	IV-E Foster Care and Adoption Subsidy Medicaid
MCFN	Non IV-E Foster Care, Adoption Subsidy and Emergency Shelter Medicaid
ME C	Extended Medicaid Due to Alimony or Spousal Support
ME I	Transitional Medicaid Due to Caretaker Income
MH H	Stand Alone Hospice Medicaid
MH M	Hospice Medicaid Supplemental to MEDS-AD (MM S)
MH S	Hospice Medicaid Supplemental to SSI Medicaid (MS)
MM C	MEDS for Children Born After 09-30-1983 (Through age 18)
MM I	MEDS for Infants Under 1 Year Old
MM P	MEDS for Pregnant Women
MM S	MEDS for Aged and Disabled
MM T	MEDS for Pregnant Women (Protected Eligibility)
MN	Presumptively Eligible Newborn Medicaid
MO Y	Low Income Family Medicaid for Age 19-20
MREI	RAP/CHEP Extended Medicaid for Earned Income
MR R	RAP/CHEP Direct Assistance Medical Assistance
MS	SSI Medicaid
MT A	Protected Medicaid for Widows 1 and Children
MT C	Regular Protected Medicaid (COLA)
MT D	Protected Medicaid for Disabled Adult Children
MT W	Protected Medicaid for Widows II
MX	Continuous Coverage for SSI child who loses SSI eligibility
MK A	MediKids (Subsidized – $15)	Full Medicaid, except institutional care in a skilled nursing facility or swing bed, ICF/IID, state mental health hospital, or HCBS waiver services. Must be enrolled in managed care to be eligible.
MK B	MediKids (Subsidized – $20)
MK C	MediKids (Full pay – $187.96)
MI A	Institutional Care Medicaid Supplemental to LIF Medicaid	Full Medicaid, including institutional care in a skilled nursing facility or swing bed, ICF/IID, or state mental health hospital.
MI I	Stand Alone Institutional Care Medicaid
MI M	Institutional Care Medicaid Supplemental to MEDS-AD (MM S)
MI S	Institutional Care Medicaid Supplemental to SSI Medicaid (MS)
MI T	Institutional Care Medicaid Failed-Transfer of Assets	Full Medicaid, except institutional care in a skilled nursing facility or swing bed, ICF/IID, state mental health hospital, or HCBS waiver services.
MW A	Medicaid Waivers	Full Medicaid, including waiver services.
ML A	AFDC Related Emergency Medical Assistance for Noncitizens	Limited to emergency care (emergency inpatient, labor and delivery, kidney dialysis).
ML S	SSI Related Emergency Medical Assistance for Noncitizens
NA R	Medically Needy for Parents, Caretakers and Children	Must meet Share of Cost. Eligibility is displayed in FMMIS on the date the recipient attains Florida Medicaid eligibility by meeting his or her share of cost, through the end of that month. Eligible for all services except: ·         Assistive care services ·         Intermediate care facilities for individuals with intellectual disabilities ·         Home and community-based services waiver programs ·         Nursing facility services ·         Regional perinatal intensive care center services ·         State mental hospital services ·         Statewide inpatient psychiatric program services.
NCFN	Non IV-E Foster Care Medically Needy
NM P	MEDS for Pregnant Women Medically Needy
NO Y	Medically Needy for Children Ages 19 thru 20
NR R	RAP/CHEP Medically Needy
NS	SSI-related Medically Needy Covers aged, blind or disabled
NL A	Family-related Emergency Medical Assistance for Noncitizens Medically Needy	Limited to emergency care (emergency inpatient, labor and delivery, kidney dialysis) for non-qualified aliens; must meet Share of Cost.
NL S	SSI-related Emergency Medical Assistance for Noncitizens Medically Needy
FP	Family Planning Medicaid	Limited to family planning services.
MU	Presumptive Eligibility for Pregnant Women	Limited to outpatient, office, transportation, and emergency room services. Does not cover inpatient or delivery services.
QMB	Qualified Medicare Beneficiaries	Limited to Medicare premiums, deductibles, and coinsurance.
QMBR	Qualified Medicare Beneficiaries (Renal Disease)
QI1	Qualifying Individuals 1	Limited to Medicare Part B premium.
SLMB	Special Low Income Beneficiaries
WD	Working Disabled	Limited to Medicare Part A premium.

(8) This rule is in effect for five years from its effective date.

Rulemaking Authority 409.919 FS. Law Implemented 409.903, FS. History–New 3-25-18, Amended 8-19-21.