To revise the Family-Related Medicaid eligibility policies and procedure used to implement the Florida Family-Related Medicaid Program so that the requirements of the Affordable Care Act that govern the Florida Family-Related Medicaid coverage ...

 

DEPARTMENT OF CHILDREN AND FAMILIES

Economic Self-Sufficiency Program

RULE NOS.:RULE TITLES:

65A-1.704Family-Related Medicaid Eligibility Determination Process

65A-1.707Family-Related Medicaid Income and Resource Criteria

65A-1.708Family-Related Medicaid Budgeting Criteria

PURPOSE AND EFFECT: To revise the Family-Related Medicaid eligibility policies and procedure used to implement the Florida Family-Related Medicaid Program so that the requirements of the Affordable Care Act that govern the Florida Family-Related Medicaid coverage groups are met.

SUMMARY: The proposed rules amend the Family-Related Medicaid Program eligibility policies and procedures used in the eligibility determination process for the Family-Related Medicaid Program.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein:

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.902, 409.903, 409.904, 409.919 FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: April 4, 2016, 1:00 p.m. ‒ 3:00 p.m.

PLACE: 1317 Winewood Boulevard, Building 3, Room 455, Tallahassee, Florida 32399-0700

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 7 days before the workshop/meeting by contacting: Vonsenita Tranquille. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Vonsenita Tranquille, Economic Self-Sufficiency Program, [phone], 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700, [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

Substantial rewording of Rule 65A-1.704 follows. See Florida Administrative Code for present text.

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

(1) Public assistance staff determine eligibility for Family-Related Medicaid at application, or when a change in conditions of eligibility is reported, or not longer than a 12 month cycle.

(2) The Department must make a redetermination of eligibility for Medicaid without requiring information from the individual if able to do so based on reliable information contained in the individual's case or other more current information available to the Department. If able to renew eligibility based on the information, the Department will send a written notice of the eligibility determination. When the Department cannot redetermine eligibility based on the information available, the individual or designated representative will need to assist the Department with the completion of the renewal determination. If a renewal cannot be made based upon information already available, the Department will provide the individual with:

(a) A notice, at least 30 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:

1. Via the internet Web site,

2. By telephone,

3. Via mail,

4. In person, or

5. By fax.

(b) Notice of the Department’s decision concerning the renewal of eligibility;

(c) Timely and adequate notice of action taken to adversly affect their eligibility or to reduce or discontinue .Medicaid benefits; and,

(d) If the individual fails to provide the information for renewal and a notice of adverse action discontinuing Medicaid benefits is sent, the individual can still provide the requested information within three monts of the date of the adverse action notice and receive up to three months retroactive coverage. The date of application determines the beginning of the three month retroactive period.

(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 Rule 65A-1.701, F.A.C., determines that the woman is eligible based on her family income. Presumptive eligibility ends when a determination for full Medicaid is made or, on the last day of the month following the month the presumptive eligibility determination is made, if an application for ongoing Medicaid coverage is not filed. Citizenship/noncitizen status and providing a social security number (SSN) are not required for eligibility as a presumptively eligible pregnant woman. A pregnant woman determined presumptively eligible may receive no more than one period of presumptive eligibility per pregnancy

(4) Presumptive Eligibility by Hospitals: The Department provides Medicaid during a presumptive eligibility period to pregnant women, infants and children under age 19, parents and caretaker relatives and former foster care children who are determined by a qualified hospital as defined in Rule 65A-1.701, F.A.C. to be presumptively eligible. The period of presumptive eligibility by hospitals begins on the date the determination is made. Presumptive eligibility ends when a determination for full Medicaid is made or, on the last day of the month following the month the presumptive eligibility determination is made, if an application for ongoing Medicaid coverage is not filed. An individual determined presumptively eligible may receive no more than one period of presumptively eligible may receive no more than one period of presumptive eligibility within a twelve-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,                                          .

 

Substantial rewording of Rule 65A-1.707 follows. See Florida Administrative Code for present text.

65A-1.707 Family-Related Medicaid Income and Resource Criteria.

(1) The Department uses the Modified Adjusted Gross Income (MAGI) based methodologies to determine the financial eligibility of individuals applying for Medicaid, unless the individual qualifies for an eligibility group for which MAGI-based methodologies do not apply. 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) Individuals whose eligibility for Medicaid does not require a determination of income by the Department including individuals receiving Supplemental Security Income (SSI).

(b) Individuals who are age 65 or older when age is a condition of eligibility.

(c) Individuals whose eligibility is being determined on the basis of being blind or disabled.

(d) Individuals who request coverage for long-term services and supports, including nursing facility services, or individuals who request a level of care in any institution equivalent to nursing facility services, or individuals who request home and community based services provided under a Medicaid waiver.

(e) Individuals who are being evaluated for Medicare cost sharing assistance.

(f) Individuals who are being evaluated for coverage as SSI-Related Medically Needy.

(2) Household income is defined as: The sum of the MAGI-based income of every individual included in the individual’s household. The income of children and tax dependents who are not expected to be required to file a tax return is not included. Exceptions to this income determination are:

(a) Income of children and tax dependents: The MAGI-based income of children who are included in the household of his or her natural, adopted or step parent, but are not expected to be required to file a tax return for the year in which eligibility is being determined, are not included in the household income of the taxpayer, whether or not such individual files a tax return.

(b) Income of individuals claimed as a tax dependent: The MAGI-based income of an individual who is included in the household of the taxpayer, but is not expected to be required to file a tax return for the year in which eligibility is being determined, is not included in the household income of the taxpayer, whether or not such tax dependent files a tax return.

(c) Income of taxpayer not claimed as a tax dependent: The MAGI-based income of an individual who expects to file a tax return for the taxable year in which eligibility is being determined, or for the taxable year in which a renewal of eligibility is being made, and does not expect to be claimed as a tax dependent, the household is the taxpayer claiming such individual.

(d) If a taxpayer cannot reasonably establish that another individual is a tax dependent of the taxpayer for the tax year in which eligibility is being determined the inclusion of such individual in the household is determined in accordance to 65A-1.707(2)(C).

(3) In determining the eligibility of an individual using MAGI-based income an amount equivalent to 5% of Federal Poverty Level (FPL) for the family size is applied to determine the eligibility of the individual. If the individual’s income is below the income limit for the coverage group the 5% is not applied if the individual is eligible without the additional 5%. This disregard is not applied in Medically Needy.

(4) Whose income is considered: Whose income is counted is determined pursant to 42 C.F.R.435.603(d). Household income is the sum of the MAGI based income as defined in 42 C.F.R. 603(e) minus the MAGI disregard referenced in 65A-1.707(3).

(5) Income standards for infants and children under age 19. The maximum income standard for infants under age 1 is 200 percent of the FPLand the maximum income standard for children ages 1 through 18 is 133 percent of the FPL.

(6) Income standard for Parents and Caretaker Relatives. The maximum income standard for parents and caretaker relatives is the State’s AFDC payment standard in effect as of July 16, 1996, converted to a MAGI equivalent standard.

(7) Income standard for Children 19 and 20. The maximum income standard for children 19 and 20 is the States’s AFDC payment standard in effect as of July 16, 1996, converted to a MAGI equivalent standard.

(8) Income standard for pregnant women. The maximum income standard for pregnant women is 185 percent of the FPL.

(9) Medically Needy Income Level (MNIL). The Department considers income in excess of the Medically Needy Income Level available to pay for medical care and services. The Department deducts the MNIL month to determine the amount of excess countable income available to meet medical care and services each month.

Rulemaking Authority 409.919 FS. Law Implemented 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 2-15-01, 11-23-04, 2-20-07, 5-6-08, 6-4-12,_____.

 

Substantial rewording of Rule 65A-1.708 follows. See Florida Administrative Code for present text.

65A-1.708 Family-Related Medicaid Budgeting Criteria.

(1) The Department uses a prospective budgeting method at the initial application and renewal of eligibility in the financial determination for Medicaid coverage. When eligibility is being determined for a prior month, the actual income and circumstances for that month shall be used.

(a) Weekly income is converted to a monthly amount by using, the conversion factor of 4.

(b) Biweekly income is converted to a monthly amount by using, the conversion factor of 2.

(c) Semi-monthly income is converted to a monthly amount by using the conversion factor of 2.

(d) When averaging income, all income from the most recent quarter provided to the State Wage Information Collection Agency (SWICA), within the Department of Revenue, shall be used if it is representative of the individual’s future earnings. The four most recent weeks of income shall be used if it is representative of the individual’s future earnings. A longer period of income history may be used if necessary to provide a more accurate indication of anticipated fluctuations in future income, for example self-employment in a seasonal industry. In budgeting income received by an individual on a contractual basis, at the option of the individual, the income is prorated over the period of the contract or counted when received.

(2) There is no asset or resources test.

(3) The Department will apply a standard disregard and a MAGI disregard, based on the household size, to determine the financial eligibility for pregnant women, infants and children ages one through five, parents and other caretaker relatives and children 19 and 20 years of age;

(4) The Department will only apply the MAGI disregard to determine the financial eligibility for children under age 6.

(5) Budget periods. At the initial determination, renewal of eligibility or when a change is reported, the financial eligibility for Medicaid is based on the current monthly household’s income and family size for each individual’s standard filing unit (SFU) projected for the entire eligibility period.

(6) Budgeting for Medically Needy individuals.

(a) Determining countable income. The Department will deduct the following amounts from income to determine the individual's countable income:

1. For individuals under age 21, parents and other caretaker relatives and pregnant women, the Department will deduct the Medically Needy Income Level (MNIL) amounts found in 65A-1.716(2), for Family-Related Medicaid coverage groups.

2. For aged, blind, or disabled individuals, the Department will deduct the MNIL amounts found in 65A-1.716(2), SSI-Related Medicaid coverage groups.

(b) Deduction of incurred medical expenses. The Department shall deduct allowable medical expenses in chronological order, by date of service. To qualify as a medical expense deduction the following criteria must be met:

1. The medical expense must be unpaid and the payment of the expenses remains the responsibility of the individual or a member of the SFU, or

2. The medical expense was incurred and paid during the previous three calendar months preceding the month of application or the month eligibility is being requested. The paid expense must not have been previously deducted from the countable income during a period of eligibility, or

3. Medical expenses reimbursed by a state or local government not funded in full by federal funds, excluding Medicaid program payments, are allowable deductions. Any other medical expenses reimbursable by a third party are not allowable deductions. Examples of recognized medical expenses include:

a. Allowable health insurance costs such as medical premiums, other health insurance premiums, deductibles and co-insurance charges; and,

b. Allowable medical expenses such as medical services, and personal care services in the home, provided or prescribed by a recognized member of the medical community.

Rulemaking Authority 409.919 FS. Law Implemented 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 2-15-01, 10-16-07,_____

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Dianna Laffey

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Mike Carroll

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: February 12, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: March 18, 2015