Eligibility Determination Process, Definitions, Special Provisions, Family-Related Medicaid Coverage Groups, Family-Related Medicaid Income and Resource Criteria, Family-Related Medicaid Budgeting Criteria
DEPARTMENT OF CHILDREN AND FAMILIES
Economic Self-Sufficiency Program
RULE NOS.:RULE TITLES:
65A-1.205Eligibility Determination Process
65A-1.701Definitions
65A-1.702Special Provisions
65A-1.703Family-Related Medicaid Coverage Groups
65A-1.707Family-Related Medicaid Income and Resource Criteria
65A-1.708Family-Related Medicaid Budgeting Criteria
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 45 No. 221, November 13, 2019 issue of the Florida Administrative Register.
65A-1.205 Eligibility Determination Process
(1) The individual completes and submits a Department application for public assistance using either the ACCESS Florida Application, CF-ES 2337, 08/2016, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, or an ACCESS Florida Web Application (only accepted electronically), CF-ES 2353, XXX, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX. The following non-English versions of the ACCESS Florida Application are incorporated by reference: CF-ES 2337C (Chinese), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337F (French-Canadian), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337H (Creole), 08/2016, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337I (Italian), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337P (Portuguese), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337R (Russian), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337S (Spanish), 08/2016, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2337SC (Serbo-Croatian), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, and CF-ES 2337V (Vietnamese), 11/2011, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, Individuals applying for Family-Related Medical Assistance only or the Children’s Health Insurance Program (CHIP) must complete and submit the Family-Related Medical Assistance Application, CF-ES 2370, 09/2015, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX. The following non-English versions of the Family-Related Medical Assistance Application are incorporated by reference: CF-ES 2370H (Creole), 09/2015, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, and CF-ES 2370S (Spanish), 09/2015, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX. The Medical Assistance Referral form, CF-ES 2039, 08/2018, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, is submitted to initiate an Emergency Medical Assistance for Noncitizens determination and is used by providers to request a Florida Medicaid ID number assignment for newborns. Applicants may apply for public assistance in person or by phone, mail, the internet, or fax. Individuals may also apply for Medicaid through the Federally Facilitated Marketplace (FFM). An application for public assistance benefits must contain at least the individual’s name, address, and signature to initiate the application process. An eligibility specialist determines the eligibility of each household member for public assistance. An applicant can withdraw the application at any time without affecting their right to reapply. An application for Medicaid coverage on behalf of a child(ren) in the care of the Department is made by completing and submitting the Child In Care Medicaid Application, CF-ES 2293, 01/2020 06/2013, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX.
(a) The Department must determine an applicant’s eligibility for public assistance initially at application and, if the applicant is determined eligible, at periodic intervals thereafter. If an applicant is determined ineligible for Medicaid benefits based on the modified adjusted gross income (MAGI) budgeting methodology as defined in subsection 65A-1.701(45), F.A.C., the Department will forward an electronic file to the Children’s Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM) for a determination of eligibility. with income that meets or exceeds 100% of the Federal Poverty Level (FPL), the Department will forward an electronic file to the FFM or the Children’s Health Insurance Program (CHIP). It is the applicant’s responsibility to keep appointments with the eligibility specialist and furnish information, documentation and verification needed to establish eligibility. If the Department schedules a telephonic appointment, it is the Department’s responsibility to be available to answer the applicant’s phone call at the appointed time. The Department will provide the applicant a written notice of action taken on the case including information on fair hearing rights. The eligibility specialist must provide assistance in obtaining information, documentation or verification when requested by the applicant or when assistance appears necessary.
(b) The Department must verify the Social Security Numbers (SSNs) for each applicant for public assistance benefits, except individuals applying for Medicaid who:
1. are not eligible to receive a SSN, ;
2. do not have a SSN,
3. and may only be issued an SSN for a valid non-work reason in accordance with 20 C.F.R. § 422.104, ; or
4. individuals who refuse to obtain an SSN because of well-established religious objections.
(c) The Department follows time standards for processing public assistance applications which vary by public assistance program type. The time standards for processing applications for the Food Assistance Program and Temporary Cash Assistance Program are set forth in 7 C.F.R. § 273.2(g)(1) and 45 C.F.R. § 206.10(a)(3)(i) and (ii), respectively. The time standard for processing applications for Medicaid is set forth in 42 C.F.R. § 435.912 (a), (b), and (c). For Food Assistance and Temporary Cash Assistance Programs, time standards begin the date following the date the application was filed and end on the date the Department makes benefits available or mails a notice concerning eligibility, whichever is earlier.
For the Medicaid Program, the time standard begins on the date of application and ends on the date the Department mails an eligibility notice. The Department must process and determine eligibility within the following time frames:
1. through 3. No change.
4. Medicaid based on disability - 90 days.
All days counted after the date of application are calendar days. Applicant delay days do not count in determining the Department’s compliance with the time standard. The Department uses information provided on the Screening for Expedited Medicaid Appointments form, CF-ES 2930, 04/2007, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, to expedite processing of Medicaid disability-related applications. The following non-English versions of the Screening for Expedited Medicaid Appointments form are incorporated by reference: CF-ES 2930H (Creole), 04/2007, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX; and CF-ES 2930S (Spanish), 04/2007, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX. The “Are You Disabled and Applying for Medicaid?” brochure, CF/PI 165-107, 06/2008, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, describes required information for Medicaid Program eligibility determinations. The following non-English versions of the “Are You Disabled and Applying for Medicaid?” brochure are incorporated by reference: CF/PI 165-107H (Creole), 06/2008, is incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX; and CF/PI 165/107S (Spanish), 06/2008, is incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX.
(d) through (h) No change.
(2) In accordance with 7 C.F.R. § 273.14(b), 45 C.F.R. § 206.10(a)(9)(iii), and 42 C.F.R. § 435.916(a) or (b), and 42 C.F.R.§ 435.919, the Department must redetermine eligibility at periodic intervals.
(a) through (b) No change.
(c) The Department will make a renewal of eligibility for Medicaid without requiring information from the individual if it is possible to do so based on reliable information contained in the individual’s case or other more current information available to the Department and send the individual a written notice concerning eligibility. The Department will request only the information needed to renew eligibility. If a renewal cannot be made based upon existing and available information, the Department will provide the individual with:
1. A notice, at least 30 calendar days prior to the end of the eligibility renewal date, informing them it is time to review their eligibility for continued benefits and the options available to complete the renewal process; and
2. A notice of the Department’s decision concerning the renewal of eligibility.; and
(d)3. The Department will reconsider the eligibility of an individual whose case is closed due to failure to submit the renewal application or to provide requested information, if the individual meets the renewal application conditions within three months after the date of closure in accordance with 42 C.F.R.§ 435.911 and 42 C.F.R. § 435.916(f).
(3) No change.
(4) If an applicant or recipient does not sign and date the application, fails to keep an appointment or reschedule with the eligibility specialist, fails to submit the required documentation or verification, or fails to request requests an extension of the due date, the Department will deny the application because it cannot establish eligibility.
(5) The Department must can substantiate information provided by the applicant or recipient as part of each determination of eligibility. For any public assistance program, when there is a question about the accuracy of the information provided, the Department will ask for additional information.
(a) through (b) No change.
(6) through (8) No change.
(9) The following additional forms, which are incorporated into this rule by reference, can be used in the eligibility determination process:
(a) Verification of Employment/Loss of Income, CF-ES 2620, 05/2010, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2620H (Creole), 05/2010, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2620S (Spanish), 05/2010, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(b) Verification of Dependent Care Expenses, CF-ES 2621, 03/2010, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2621H (Creole), 03/2010, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2621S (Spanish), 03/2010, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(c) Verification of Shelter Expenses, CF-ES 2622, 03/2010, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2622H (Creole), 03/2010, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2622S (Spanish), 03/2010, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(d) School Verification, CF-ES 2623, 10/2005, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2623H (Creole), 10/2005, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2623S (Spanish), 10/2005, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(e) Work Calendar, CF-ES 3007, 10/2005, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 3007H (Creole), 10/2005, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 3007S (Spanish), 10/2005, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(f) Designation of Beneficiary, CF-ES 990, 01/2020 10/2005, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX;
(g) No change.
(h) Authorization to Disclose Information, CF-ES 2514, 02/2007, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2514H (Creole), 02/2007, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2514S (Spanish), 02/2007, available at is https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX; and
(i) Financial Information Release, CF-ES 2613, 10/2005, available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX, CF-ES 2613H (Creole), 10/2005, is available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX.
65A-1.701 Definitions
(1) through (4) No change.
(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) the Department determines the individual requires; 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) through (17) No change.
(18) Developmental Disabilities Individual Budgeting (iBudget) Waiver: A Medicaid HCBS Program for persons with intellectual disabilities.
(19) through (31) are renumbered (18) through (30) No change.
(31)(32) iBudget Florida Developmental Disabilities (DD) Waiver: A home and community-based waiver program for individuals diagnosed before age 18 with a developmental an intellectual (mental) 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.
(32)(33) Income: For Family-Related Medicaid Programs refer to 65A-1.707, F.A.C. For SSI-Rrelated programs refer to 20 C.F.R. § 416.1100 and 65A-1.713, F.A.C.
(34) through (45) are renumbered (33) through (44) No change.
(45)(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 65A-1.707(2)F.A.C.
(47) through (55) are renumbered (46) through (54) No change.
(55)(56) Qualified Hospital: A hospital that is an approved Medicaid provider under Florida’s the Florida Medicaid State Plan and approved to make presumptive eligibility determinations as outlined by AHCA.
(57) through (66) are renumbered (56) through (65) No change.
(66)(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. Determined based on the converted data and figure of the Federal Poverty Level (FPL) and an average of the expenses and deductions allowed for a filing unit receiving assistance under the Florida Medicaid State Plan. The amount is deducted from the total gross income to determine if the “Countable Net Income” is at or below the income limit for the coverage group based on the size of the filing unit.
(68) through (74) are renumbered (67) through (73) No change.
65A-1.702 Special Provision
(1) No change.
(2) Processing Medicaid Applications for Supplemental Security Income (SSI) Denials.
(a) No change.
(b) The Department will identify the individuals for whom the Department does not have an open Medicaid case or a pending Medicaid application at the time the SDX data is received. The Department will explore eligibilty under another coverage group with information based on available information receieved from the SDX data. If additional information is required to make a determination, tThese individuals or their SSA payee will be notified in writing to contact the Department within 30 calendar days. Failure to do so without good cause, will result in the issuance of a written notice of Medicaid denial for failure to follow through in determining eligibility.
(c) through (e) No change.
(3) through (9) No change.
(10) Limits of Coverage.
(a) through (c) No change.
(d) Qualifying Individuals 1 (QI1). Under QI1 coverage, individuals are eligible for payment of their Medicare Part B premium. (This is coverage for individuals who would be eligible for QMB or SLMB coverage except that their income exceeds the limits for those programs.) If eligible, AHCA will pay the premium for up to three months retroactive to the month of application.
(11) through (14) No change.
65A-1.703 Family-Related Medicaid Coverage Groups
(1) No change.
(2) For each coverage group listed in subsection (1) above there is no asset or resource limit, and the following additional criteria must be met to qualify under the specific coverage group:
(a) Children under age 19 and ages 19 to 21, the child must have never been married or emancipated, and must meet the eligibility criteria of Title XIX of the Social Security Act and the general requirements specified in 65A-1.705, F.A.C. The countable net income for a child is based on the filing unit/family size of the coverage group. To determine eligibility for a child, if the countable net income is at or above the limit for the coverage group, the MAGI five percent disregard for the filing unit/family size is subtracted from the countable net income to determine if the child will qualify. If the countable net income for the child is below the income limit of the coverage group, the MAGI five percent disregard is not applied. Income limits are based on the coverage group, the filing unit/family size of the child and listed below, as follows;
1. through 3. No change.
4. The countable net income for the filing unit/family size of a child age 19 to 21, must be less than or equal to the income limits included in Florida’s the Florida Medicaid State Plan.
5. No change.
(b) No change.
(c) Children placed for adoption and adopted children are:
1. Children under the age of 18 for whom there is a state adoption assistance agreement in effect, other than under Title IV-E of the Social Security Act, between the state and an adoptive parent. In addition to the adoption assistance agreement, the state adoption agency shall determine;
a. If the child has a pre-existing special need for medical or rehabilitative care that would have precluded adoption placement without receipt of Medicaid coverage under Florida’s the Florida Medicaid State Plan, and
b. No change.
2. No change.
(d) No change.
(e) Parents (natural or adoptive), caretaker relatives and their spouses may derive their eligibility from a child under age 18 (natural or adoptive) within the fifth degree of the relationship who has never married and is not emancipated residing with them, provided their filing unit/family size is equal to or below the income limit established in the Florida’s Medicaid State Plan for the coverage group. The fifth degree of relationships includes the following individuals:
1. through 4. No change.
(f) No change.
(3) No change.
65A-1.707 Family-Related Medicaid Income and Resource Criteria
(1) The Department uses the Modified Adjusted Gross Income (MAGI) based budgeting methodologies as defined in 26 U.S.C. section 36B(d)(2)(B) of the Internal Revenue Code to determine the financial eligibility of individuals applying for Medicaid. Resources are not considered as part of the eligibility determination for individuals whose eligibility is determined using MAGI methodologies. MAGI methodologies will not apply to the following:
(a) through (f) No change.
(2) Countable Net income is defined as: The sum of income counted for the assistance group based on the number of individuals and their income included in the SFU, except as provided in 42 C.F.R. § 435.603(d)(4). To determine eligibility using MAGI-based income criteria, an amount equivalent to the MAGI five percent of the Federal Poverty Level (FPL) is subtracted from the countable income of the individual based on the size of the SFU. The standard disregard as defined at 65A-1.701(67) is subtracted from total gross income to determine countable net income. The MAGI five percent is not applied if the countable net income of the individual is at or below the income limit for the coverage group. This disregard is not applied in Medically Needy.
(3) MAGI-based income is defined as: Income calculated using the same financial methodologies used to determine modified adjusted gross income as defined in section 26 U.S.C. 36B(d)(2)(B) of the Internal Revenue Code, with the exceptions specified in 42 C.F.R. § 435.603(e).
(4) SFU Household: Refer to 65A-1.705(2), F.A.C., for information on households.
(5) Income standard for infants and children under age 19: The maximum income standard for infants under age one is 200 percent countable net income of the MAGI converted FPL and the maximum income standard for children ages one through 18 is 133 percent of the FPL, pursuant to Florida’s Medicaid State Plan, Approved Conversion Thresholds, 6/27/13, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX and https://ahca.myflorida.com/Medicaid/stateplan_aca.shtml.
(6) Income standard for Parents and Caretaker Relatives: The maximum income standard for parents and caretaker relatives is the state’s Aid to Families with Dependent Children (AFDC) payment standard in effect as of July 16, 1996, converted to a MAGI equivalent standard included in Florida’s the Florida Medicaid State Plan, Approved Conversion Thresholds Standards, 06/2013, incorporated by reference and available at https://www.flrules.org/gateway/reference.asp?NO=Ref-XXX.
(7) Income standard for children ages 19 and 20. The maximum income standard for children ages 19 and 20 is the state’s AFDC payment standard in effect as of July 16, 1996, converted to a MAGI equivalent standard included in Florida’s the Florida Medicaid State Plan, Approved Conversion Thresholds Standards.
(8) Income standard for pregnant women. The maximum income standard for pregnant women is 185 percent of the FPL as specified in Florida’s Medicaid State Plan, Approved Conversion Thresholds.
(9) Medically Needy Income Level (MNIL). The Department deducts the MNIL, as provided in 65A-1.716(2) F.A.C., from the SFU countable income to determine the amount of excess countable income Share of Cost (SOC) available to meet medical care and services each month.
(10) No change.
65A-1.708 Family-Related Medicaid Budgeting Criteria
(1) through (2) No change.
(3) The Department will apply the standard disregard as defined in 65A-1.701(66)(68) F.A.C., based on the standard filing unit size to all budgets using the Family-Related Medicaid budgeting criteria except Medically Needy Need.
(4) No change.
