65A-1.701. Definitions

As used in Rules 65A-1.701 through 65A-1.716, F.A.C., the following terms have the following meanings unless a different meaning is given:

(1) Adoption Subsidy: A monthly payment to assist adoptive parents in caring for an adopted child who has been determined to meet the eligibility criteria of a special needs child.

(2) Adoptive Parent: A person who provides a child(ren) a permanent home through a court process, that once final, names the adoptive parent as the child’s legal parent.

(3) Affordable Care Act (ACA): The Patient Protection and Affordable Care Act in accordance with 42 U.S.C. §18001 et seq.

(4) Agency for Health Care Administration (AHCA): The designated single state agency responsible for the administration of the Florida Medicaid Program.

(5) Appropriate Placement: Placement of an individual into a Medicaid participating nursing facility that provides the type and level of care determined by the Florida Department of Elder Affairs (DOEA), Comprehensive Assessment and Review for Long-Term Care Services (CARES) or the receipt of approved Home and Community Based (HCBS) waiver services by an individual in accordance with an approved plan; or the receipt by an individual of hospice services provided by a Medicaid participating hospice provider; or by an individual in accordance with 42 U.S.C. §1396d.

(6) Assistance Group: All individuals within the standard filing unit (SFU) who are potentially eligible for benefits. For Family-Related Medicaid eligibilty, all applicants are considered to be an assistance group of one.

(7) Asset Verification System (AVS): The electronic verification process by which the Department verifies disclosed and undisclossed assets for individuals applying for Medicaid based on age or disability.

(8) Caretaker relative: A dependent child’s relative by blood, adoption, or marriage with whom the child is living, and who is assuming primary responsibility for the child’s care. The relative must be one of the following:

(a) The child’s legal or biological father, mother, grandfather, grandmother, brother, sister, including those of half-blood, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, first cousin once removed, nephew, or niece; and persons of preceding generations as denoted by prefix of “grand”, “great”, “great-great”, “great-great-great”, etc.; or

(b) The present or former spouse of a person listed in (a) above, even after the marriage is terminated by death or divorce.

(9) Child: A natural, adopted or stepchild.

(10) Child-Placing Agency: A child welfare agency that is any institution, society, agency, or facility which places children in foster homes for temporary care or in prospective adoptive homes for adoption.

(11) Children’s Health Insurance Program (CHIP): Premium health insurance coverage for children under age 19, as referenced in Rule 65A-1.703, F.A.C.

(12) Code: The Internal Revenue Code of Rules and Regulations.

(13) Community Spouse: The legal spouse of a married individual who lives in the community when one spouse is in or seeking institutional care.

(14) Community Spouse Income Allowance: The portion of an institutionalized spouse’s monthly income, if any, which may be protected for the community spouse’s maintenance needs if agreed to by the institutionalized spouse.

(15) Community Spouse Resource Allowance: The portion of the couple’s total assets which is protected for the community spouse and not considered to be available to the institutionalized spouse for purposes of determining eligibility.

(16) Coverage Group: A classification under which one or more individuals may be eligible for benefits.

(17) Department: The Department of Children and Families (DCF).

(18) Dependent: The person who depends upon another person for all or part of their support or maintenance.

(19) Eligible Couple: A married couple with both persons meeting the criteria for Medicaid eligibility. See the definition for “spouse.”

(20) Enrollment: The status of an individual who satisfies the non-financial and resource eligibility criteria for the Medically Needy Program but who is not eligible for any benefits until their share of cost is met.

(21) Excess Shelter Allowance: The amount by which the sum of a community spouse’s shelter expenses and the standard utility allowance exceeds 30 percent of the Minimum Monthly Maintenance Needs Allowance (MMMNA).

(22) Ex Parte Determination: An exploration of Medicaid eligibility under another Medicaid coverage group when an individual is no longer eligible under their current Medicaid coverage group based on available information.

(23) Familial Dysautonomia (FD): A home and community-based waiver program designed specifically for individuals who are diagnosed with this genetic disorder. The waiver provides support and services that will minimize the effects of the disease and stabilize the health of the participant to remain in a noninstitutionalized setting in the community. Participants for this waiver group must be age three through age 64.

(24) Family Size: The number of persons counted as members of an individual’s SFU.

(25) Federal Benefit Rate (FBR): Income standard levels established by the federal government to determine income eligibility and payment benefits for the Supplemental Security Income (SSI) Program.

(26) Federally Facilitated Marketplace (FFM): A federally designated entity used by small businesses and individuals to find, compare, and purchase qualified health plans.

(27) Foster Care: Twenty-four-hour substitute care for children removed by the courts and placed away from their parents or guardians and for whom the State agency has placement and care responsibility. This includes, but is not limited to, placements in foster family homes, foster homes of relatives, group homes, emergency shelters, residential facilities, child care institutions, and preadoptive homes.

(28) Home and Community-Based Services Waiver (HCBS): A Waiver authorized under section 1915(c) of the Social Security Act. HCBS Waivers are designed to provide services for a particular targeted population based on the individual’s need for care and support that will delay or prevent institutionalization.

(29) Hospice: A coverage group which provides care and support to individuals who are terminally ill (with a life expectancy of six months or less).

(30) Hospital Swing Beds: Medicaid approved beds in rural hospitals designated to provide acute hospital care or nursing facility care.

(31) Household: Individuals residing together whose presence in the home may affect the eligibility of other individuals residing in the home.

(32) iBudget Florida: A home and community-based waiver program for individuals diagnosed before age 18 with a developmental disability, as defined in Section 393.063(12), F.S. The waiver provides support and services that will assist with stabilizing the health and welfare of the individual in a noninstitutionalized setting in the community.

(33) Income: For Family-Related Medicaid Programs refer to Rule 65A-1.707, F.A.C. For SSI-Related programs refer to 20 C.F.R. §416.1100 and Rule 65A-1.713, F.A.C.

(34) Institutional Care Program (ICP): A program that helps to pay for the cost of care in a nursing facility and provides Medicaid coverage.

(35) Institutional Vendor Payment: The payment made by the Medicaid Program to a Medicaid licensed nursing facility for the medical care of eligible individuals.

(36) Institutionalized Individual: An inpatient in a nursing facility, hospital swing bed, hospital distinct-part skilled nursing facility, or intermediate care facility for the developmentally disabled for whom Medicaid payments are paid based on the level of care provided.

(37) Institutionalized Spouse: An inpatient or individual seeking placement in a medical or nursing facility who is legally married to a community spouse.

(38) Intermediate Care Facility for individuals with Intellectual Disabilities (ICF/ID): An institution or distinct part of an institution for treatment, care or rehabilitation of the developmentally disabled or persons with related conditions as set forth in 42 C.F.R. §435.1010. These were formerly called “intermediate care facilities” for the mentally retarded (ICF/MR).

(39) Lawfully Residing Child: A child under the age of 19 who has a lawful immigration status or a qualified noncitizen status as provided for in the Immigration and Nationality Act.

(40) Medically Needy: Coverage which provides Mediciad eligibility for individuals whose countable income exceeds the applicable Medically Needy Income Levels (MNIL) in subsection 65A-1.716(2), F.A.C.

(41) Medically Needy Income Level (MNIL): Income in excess of the Medically Needy Income Level available to pay for medical care and services.

(42) Medicaid for Aged and Disabled (MEDS-AD): Medicaid coverage group for aged and disabled individuals with income at or below 88 percent of the federal poverty level.

(43) Minimum Monthly Maintenance Needs Allowance (MMMNA): The minimum monthly maintenance needs allowance recognized by the state for the community spouse of an institutionalized individual.

(44) Model Waiver: A home and community-based waiver program for individuals diagnosed with degenerate spinocerebellar disease. The waiver provides support and services that will assist with stabilizing the health and welfare of an individual to remain in a noninstitutionalized setting in the community. Participants for this waiver group are age 20 or younger.

(45) Modified Adjusted Gross Income (MAGI): The financial methodologies set forth in 42 C.F.R. §435.603 to determine the financial eligibility of all individuals for Medicaid, except for individuals identified in 42 C.F.R. §435.603(j).

(46) Modified Adjusted Gross Income (MAGI) Disregard: An amount that may be subtracted from net countable income of the SFU as provided for in 42 C.F.R. §435.603(d)(4) and subsection 65A-1.707(2), F.A.C.

(47) Modified Project Aids Care: A limited coverage group for individuals diagnosed with the Human Immunodeficiency Virus (HIV) Acquired Immunodeficiency Deficiency Syndrome (AIDS), who do not meet the criteria for enrollment in the Statewide Medicaid Managed Care Long Term Care Program and meet other program requirements.

(48) Non-Filer: An individual who is not required to file a tax return and does not expect to be claimed as a tax dependent on another person’s tax return.

(49) Others Outside of the Household (OOTH): An individual not living in the home, whom the tax-filer intends to claim on their federal tax return or an individual outside the home who intends to claim an individual on their federal tax return.

(50) Parent: A natural, legal, adoptive parent, or stepparent.

(51) Patient Responsibility: The amount by which AHCA must reduce its payments to a medical institution or intermediate care facility, or reduce its payments for home and community-based services provided to an individual towards their cost of care.

(52) Presumptive Eligibility by Hospitals: An abbreviated determination of eligibilty completed by a qualified hospital approved by AHCA.

(53) Program of All-Inclusive Care for the Elderly (PACE): An optional Medicaid program intended to serve the frail and elderly in the home and community. The PACE program includes a comprehensive medical and social service delivery system using an interdisciplinary team approach in an adult day health center that is supplemented by in-home and referral services in accordance with participants’ needs.

(54) Qualified Designated Provider (QDP): An entity approved to conduct presumptive eligibility determinations for Medicaid for pregnant women.

(55) Qualified Disabled Trust: A trust established by a parent, grandparent, legal guardian, or court on or after October 1, 1993, or a trust created by the individual if created on or after December 13, 2016, for the sole benefit of a disabled individual under the age of 65 which may consist of the disabled individual’s resources and income. The trust must provide that upon the death of the disabled individual the State shall receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of the disabled individual by the Medicaid program pursuant to the state’s Title XIX state plan.

(56) Qualified Hospital: A hospital that is an approved Medicaid provider under Florida’s Medicaid State Plan and approved  to make presumptive eligibility determinations as outlined by AHCA.

(57) Qualified Income Trust: A trust established on or after October 1, 1993, for the benefit of an individual whose income exceeds the ICP income standard and who needs institutional care or HCBS. The trust must consist of only the individual’s pension, Social Security and other income. The trust must be irrevocable and provide that upon the death of that individual the State shall receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of that individual pursuant to the state’s Title XIX state plan.

(58) Qualified Noncitizen: A category of noncitizens who meet at least one of the sections of the Immigration and Nationality Act, 8 U.S.C. §1101 et seq., which allows them to receive Medicaid.

(59) Qualified Pooled Trust for the Disabled: A trust established by a disabled individual’s parent, grandparent, or legal guardian, or a court on or after October 1, 1993, for the sole benefit of the disabled individual and managed by a non-profit or not-for-profit association as defined in the Internal Revenue Code. A separate account must be maintained for each disabled beneficiary. For investment and management purposes, the separate accounts may be pooled together. To the extent that any amounts remaining in the beneficiary’s account upon their death are not retained by the trust, the trust must provide that upon the death of the disabled beneficiary, the State shall receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of that individual pursuant to the state’s Medicaid Title XIX state plan.

(60) Reasonably Compatible Income: Income reported that is consistent with information verified by an electronic data source and does not vary in a way that is meaningful for eligibility. Information is considered verified when the difference between reported income and information from electronic sources is no more than 10 percent.

(61) Resource Allowance: The amount of the couple’s total countable resources which may be allocated to the community spouse of an institutionalized person.

(62) Resources: Cash or other liquid assets, or any real or personal property that an individual owns and could convert to cash to be used for their support and maintenance. The terms “resources” and “assets” are used interchangeably in this rule chapter.

(63) Retroactive Coverage: The provision that allows individuals to apply for Medicaid for any of the three months prior to the month of application for Medicaid.

(64) Share of Cost (SOC): The amount of the individual’s or family’s income that exceed the Medically Needy Income Level (MNIL). A SOC represents the amount of allowable medical expenses that a Medically Needy assistance group must incur each month before becoming eligible to receive Medicaid.

(65) Sibling: A natural, adopted, or step brother or sister.

(66) Spouse: An individual lawfully married to another individual under state statute, federal regulation and federal laws.

(67) Standard Disregard: An amount based on the FPL and an average of the expenses and deductions allowed for a coverage group pursuant to Florida’s Medicaid State Plan, Approved Conversion Thresholds.

(68) Standard Filing Unit (SFU): All individuals whose needs, income, and/or assets are considered in the determination of eligibility for a category of assistance.

(69) Statewide Medicaid Managed Care Long Term Care (SMMC-LTC): A program for individuals who need long term care, support and services in nursing homes, in their own homes or other community-based settings.

(70) Tax Dependent: Someone for whom a deduction may be claimed under the Internal Revenue Service (IRS) tax code.

(71) Tax-Filer: An individual required to file federal income taxes and who claims the exemption amounts cited in 42 C.F.R. §435.603(f).

(72) Temporary Absence: A period of time for which Medicaid may continue when an otherwise eligible member is out of the home.

(73) Title XVI: The provisions of the Social Security Act that set forth Supplemental Security Income (SSI) policies and procedures. The terms “Title XVI” and “SSI” are used interchangeably in this rule chapter.

(74) Title XIX: The provisions of the Social Security Act that set forth Medicaid policies and procedures. The terms “Title XIX” and “Medicaid” are used interchangeably in this rule chapter.

(75) Working People with Disabilites (WPwD) eligibility: The increased income and resource limits allowed to indviduals aged 21 and older with earned income and who are enrolled in a HCBS waiver.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History–New 10-8-97, Amended 2-15-01, 4-1-03, 6-13-04, 8-10-06, 3-25-20, 9-22-21.