65A-1.704. Family-Related Medicaid Eligibility Determination Process

(1) Public assistance staff determine eligibility for Family-Related Medicaid in accordance with Rules 65A-1.703, 65A-1.705 and 65A-1.707, F.A.C., at the time of the initial application and annually thereafter and when a change potentially affecting eligibility is reported.

(2) The Department must make a redetermination of eligibility for Medicaid without requiring information from the individual if it is able to do so based on reliable information contained in the individual's case or other more current information available to the Department.

(a) If the Department is able to renew eligibility based on the information available, the Department will send a written notice of the eligibility determination to the individual.

(b) If the Department is unable to redetermine eligibility based on the information available, the Department will provide the individual with:

1. A notice, at least 30 calendar days prior to the end of the eligibility redetermination date, that it is time to renew their eligibility and the options available to the individual to complete the redetermination. These options are:

a. Via the internet Web site,

b. By telephone,

c. Via mail,

d. In person, or

e. By fax.

2. If the individual fails to provide the information for renewal, eligibility cannot be determined, and coverage will end. A notice of adverse action advising the individual of the Department’s actions will be sent. Medicaid coverage will be reinstated back to the effective date of the closure if the individual provides the requested information within three months of the effective date of the closure and continues to be eligible.

(3) Presumptive Eligibility for Pregnant Women. Qualified Designated providers determine presumptive eligibility for pregnant women. The period of presumptive eligibility for pregnant women begins when a qualified designated provider, as defined in subsection 65A-1.701(53), F.A.C., determines that the woman is eligible. Presumptive eligibility ends when a determination (approved or denied) for full Medicaid is made, or on the last day of the month following the month the presumptive eligibility determination was made, if an application for ongoing Medicaid coverage is not filed. Citizenship status and providing a social security number (SSN) are not required for eligibility. A pregnant woman determined presumptively eligible may receive no more than one presumptive eligibility period per pregnancy.

(4) Presumptive Eligibility by Hospitals. Pregnant women, infants and children under age 19, parents and caretaker relatives and former foster care children may receive Medicaid eligibility during a presumptive period when determined eligible by a qualified hospital, as defined in subsection 65A-1.701(56), F.A.C. The period of presumptive eligibility begins on the date the determination is made. Presumptive eligibility ends when a determination (approved or denied) for full Medicaid is made, or on the last day of the month following the month the presumptive eligibility determination was made, if an application for ongoing Medicaid coverage is not filed. An individual may receive no more than one presumptively eligibility determination during a 12-month period, starting with the effective date of the initial presumptive eligibility period.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 2-7-01, 10-21-01, 4-1-03, 2-4-04, 6-26-08, 8-10-10, 2-26-20.