To revise the Family-Related Medicaid eligibility policies, procedures, and forms used to implement the Medicaid Program so that the requirements of the Affordable Care Act that govern the Florida Medicaid coverage groups are met.

 

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-1.705Family-Related Medicaid General Eligibility Criteria

65A-1.716Income and Resource Criteria

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

SUMMARY: The proposed rules amend the Medicaid Program eligibility policies, procedures, and forms used in the eligibility determination process for the 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: The Department considered the factors in Section 120.541, F.S. The proposed rule is not expected to exceed the criteria in paragraph 120.541(2)(a), F.S., therefore, legislative ratification is not required under subsection 120.541(3), F.S.

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, 414.095, 414.45 FS.

LAW IMPLEMENTED: 409.902, 409.903, 409.904, 409.906, 409.919, 409.1451 (5)(b)(7)414.045, 414.095, 414.31, 414.41 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 5, 2016, 10:00 am ‒ 12:00 pm

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-1.205 follows. See Florida Administrative Code for present text.

65A-1.205 Eligibility Determination Process

(1) The individual completes and submits a Department application for public assistance to the best of the individual’s ability using either the ACCESS Florida Application, CF-ES 2337, 03/2015 , https://www.flrules.org/gateway/reference.asp?NO=Ref-00981, incorporated by reference, or an ACCESS FloridaWeb Application (only accepted electronically), CF-ES 2353, 12/2013, https://www.flrules.org/gateway/reference.asp?NO=Ref-00982, incorporated by reference. Individuals applying for Family-track medical assistance only or Children’s Health Insurance Program (CHIP) should complete and submit the Family-Related Medical Assistance Application, CF-ES 2370, 12/2013, incorporated by reference, http://www.dcf.state.fl.us/programs/access/docs/Family_Medicaid_App.pdf . Applicants may apply for public assistance in person or by phone, mail, the internet or fax.

For food assistance the application form 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, 05/2010, http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=368, incorporated by reference.

(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 the applicant is determined ineligible for Medicaid benefits, based on the modified adjusted gross income (MAGI) budgeting methodology, the Department will forward the application form to Children’s Health Insurance Program (CHIP), or to the Federally Facilitated Marketplace (FFM). 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 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 eligible individual for public assistance benefits.

(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. Expedited Food Assistance -7 days.

2. Food Assistance -30 days.

3. Refugee Assistance, Medicaid, Temporary Cash Assistance, Optional State Supplementation ,Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI1) and Qualified Disabled and Working Individuals (WD) -45 days.

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, http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=170, incorporated by reference, to expedite processing of Medicaid disability-related applications. The “Are You Disabled and Applying for Medicaid?” brochure, CF/PI 165-107, 06/2008, http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?Form ID=165, incorporated by reference, describes required information for Medicaid Program eligibility determinations.

(d) If the eligibility specialist determines during the interview or at any time during the processing of the application that the applicant must provide additional information or verification, or that a member of the assistance group must register for employment services, the eligibility specialist must give the applicant written notice to provide the requested information or verification, or to comply with the work registration process, allowing ten calendar days from the date of a notice for additional information or verification or the interview date, whichever is later, to comply.

(e) For all programs, if the requested verifications are not returned within ten calendar days from the date of written request or the interview, or 60 days from the date of application, whichever is later, the application will be denied unless the applicant requests an extension prior to the due date or there are extenuating circumstances justifying the additional extension.

(f) For Medicaid only applications, when the applicant must provide medical information, the due date is 30 calendar days following the date of a written request for such information or the interview date, or 60 days from the date of application, whichever is later.

(g) If the due date falls on a state holiday or weekend, the due date deadline is the next business day. In accordance with 42 C.F.R. § 435.912 (c)(1) and (2), the types of unusual circumstance that might affect the application processing time for Medicaid applications include applicant delay, physician delay and emergency delay as defined below. Unusual circumstances are non-agency application processing delays, and the calendar time passing during such delay period(s) does not count as part of the 90-day application processing time standard for determining the timeliness of Medicaid eligibility decisions based on disability.

1. “Applicant delay” days are the number of calendar days attributed to the applicant that causes the eligibility decision to be made after the established time standard. Applicant delay can result from an applicant  missing a scheduled appointment or failure to provide requested eligibility information, including requested medical information, or requested verification. Applicant delay begins the date the applicant misses the deadline for the required action and ends the date the applicant takes the required action

2. “Physician delay” days are the number of calendar days attributed to the applicant’s physician(s) that causes the eligibility decision to be made after the established time standard. Physician delay can result from a physician not providing requested medical evidence or from conducting a medical examination timely. Physician delay begins ten days after the Department makes its initial request for medical evidence from the physician and ends the date the Department receives complete medical evidence that is responsive to the Department’s request; or, physician delay begins fourteen days after the Department requests a medical examination and ends the date the Department receives the complete medical examination results.

3. “Emergency delay” days are the number of calendar days attributed to situations that are beyond the control of the Department that causes the eligibility decision to be made after the established time standard. Emergency delay can result from disasters, unexpected office closure(s), and unexpected or unscheduled computer systems inaccessibility or unavailability. Emergency delay begins the day such an event begins and ends the day the Department is able to resume application processing.

(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 435.919 the Department must redetermine eligibility at periodic intervals.

(a) A complete eligibility review is the process of reviewing all factors related to continued eligibility of the assistance group.

(b) A partial eligibility review entails a review of one or more, but not all factors of eligibility. The Department schedules partial reviews based on known facts or anticipated changes in circumstances concerning the assistance group. The partial review does not usually require an interview unless needed to obtain the necessary information. The Department will complete a review of an unanticipated change concerning the assistance group when the  change is reported.

(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. For individuals who are not requesting assistance, the Department will collect information in accordance with 42 C.F. R. §435.907(e). 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 days prior to the end of the eligibility renewal date, that it is time to review their eligibility for continued benefit and the options available to them to complete the renewal process; and

2. Notice of the Department’s decision concerning the renewal of eligibility.

(a) The Department will give the individual timely and adequate notice of action taken that adversely affects their eligibility or to reduce or discontinue Medicaid benefits.

(b) The Department will reconsider the eligibility of an individual who 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.

(3) The Department conducts phone or face-to-face interviews with applicants and recipients, or their authorized or designated representatives, when required for the application or to complete the eligibility review process. The Department conducts face-to-face interviews, upon request, in the Office of Economic Self-Sufficiency Program Offices, at the applicant’s or recipient’s home, or at other mutually agreed upon locations. The applicant or recipient, or their authorized or designated representative, must keep the interview appointment or reschedule a missed appointment. The Department mails a notice of missed interview to food assistance households who miss an interview.

(4) If an applicant or recipient does not sign and date the application, fails to keep an appointment or reschedule with the eligibility specialist; not sign and date the submit the required documentation or verification, or request an extension of due date, the Department will deny the application because it cannot establish eligibility.

(5) The Department 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) Substantiation establishes accuracy of information by obtaining consistent, supporting information from the individual or other third parties.  The information can be obtained or provided electronically, telephonically, in writing, or by personal contact.

(b) Documentation establishes the accuracy of information by obtaining and including in the case record an official document that supports the tatement(s) made by the individual.

(6) The Department conducts data exchanges with other agencies and systems to obtain relevant public assistance eligibility information on each applicant, recipient, and members of the Standard Filing Unit. It uses data exchanges to verify or identify social security numbers, verify the receipt of other benefits from other sources or programs, verify other eligibility information reported by the applicant or recipient, and to discover  unreported relevant eligibility information. For Medicaid eligibility, information obtained from the Federal Data Services Hub (FDSH) and State Wage Information and Collection Agency (SWICA) is considered verified upon receipt and does not require third party verification.

(a) The Department conducts data exchanges with the Social Security Administration, the Internal Revenue Service, the Florida Department of Economic Opportunity, the Florida Department of Lottery, the Federal data Services Hub, the Florida Department of Corrections, federal and state personnel and retirement systems, other states’ public assistance programs and files and educational institutions.

(b) The Department compares information obtained through data exchanges with the information already on file. If the data exchange identifies new or different information than what is already on file, the Department conducts a partial eligibility review to determine whether benefit levels must change.

(c) The Department considers beneficiary and Supplemental Security Income (SSI) benefit data from the Social Security Administration, unemployment compensation benefits, the Department of Health, Department of Corrections and information obtained from the Office of Vital Statistics verified upon receipt and does not require third party verification. Other information and data obtained by the Department may require third party verification before the Department will rely upon it to take adverse actions on a case. The Department accepts self attestation of information when reasonably compatible with electronically verified information needed to determine the eligibility of an individual for Medicaid except where the law requires other procedures (such as citizenship and immigration status). If the information provided by or on behalf of an individual is consistent with the information obtained by the Department, the Department will determine or renew eligiblity based on such information unless questionable.

(d) The Department will collect additional information to determine eligibility for Medicaid on any basis other than the MAGI Standard, and furnish Medicaid on such basis for the following:

1. Individuals whom the Department identifies based on information contained in the application as potentially eligible on a basis other than the MAGI standard;

2. Individuals who otherwise request a determination of eligibility on a basis other than the applicable MAGI standard.

(7) The Department will collect information for individuals who are not requesting assistance in accordance with 42 C.F.R. §435.907(e).

(8) In accordance with Food Assistance Program waivers, food assistance applicants and recipients who have been interviewed, but have not returned the requested verification by the due date, can be denied prior to the 30th day. Face-to-face interviews are not required.

(9) The following additional forms, which are incorporated into this rule by reference, can be used in the eligibility determination process: Verification of Employment/Loss of Income, CF-ES 2620, 05/2010; http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=197 ; Verification of Dependent Care Expenses, CF-ES 2621, 03/2010; http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=198; Verification of Shelter Expenses, CF-ES 2622, 03/2010; http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=442; School Verification, CF-ES 2623, 10/2005; http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=516; and Work Calendar, CF-ES 3007, 10/2005, http://dnp1.dcf.state.fl.us/DCFForms/Search/OpenDCFForm.aspx?FormId=348. Copies of these forms can be obtained upon request made to the Office of Economic Self-Sufficiency Headquarters Office, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700 or on the Department’s web site at http://www.dcf.state.fl.us/DCFForms/Search/DCFFormSearch.aspx

Rulemaking Authority 409.919, 414.095, 414.45 FS. Law Implemented 409.903, 409.904, 409.919, 414.045, 414.095, 414.31, 414.41 FS. History–New 4-9-92, Amended 11-22-93, 8-3-94, Formerly 10C-1.205, Amended 11-30-98, 9-27-00, 7-29-01, 9-12-04, 9-11-08, 7-1-10, 2-20-12,_______.

 

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

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 children a permanent home through a court process, that once final, names the adoptive parents as the child’s legal parents.

(3) Adult Cystic Fibrosis Waiver (ACF): A Home and Community Based Services (HCBS) Waiver program. A waiver that serves participants who are 18 years or older and who have a diagnosis of Cystic Fibrosis. Cystic Fibrosis is an inherited disease that afffects the lungs, digestive system, sweat glands and male fertility.

(4) Affordable Care Act (ACA): The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152), as amended by the 3% Withholding Repeal and Job Creation Act (Pub. L. 112-56).

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

(6) Appropriate Placement: Placement of an individual into a Medicaid-participating nursing facility that provides the type and level of care the Department determines the individual requires; or the receipt of approved HCBS waiver services by an individual in accordance with an approved plan; or the receipt by an indivudal hospice services provided by a Medicaid-participating hospice provider by an individual in accordance with 42 U.S.C. § 1396d.

(7) Assistance Group: All individuals within the standard filing unit who are potentially eligible for benefits.

(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: An unmarried individual under the age of 21.

(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(1), F.A.C..

(12) Code: The Internal Revenue rules and regulations.

(13) Community Spouse: The legal spouse of a married couple 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) unless otherwise specified.

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

(19) Developmental Disabilities Individual Budgeting (iBudget) Waiver: A Medicaid HCBS Program for persons with intellectual disabilities

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

(21) 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.

(22) 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).

(23) Familial Dysautonomia (FD): An HCBS waiver program that provides support and services to persons living in their own homes or family homes.

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

(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: Substitute care for children placed away from their parent(s) or guardian(s) and for whom the state or tribal 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) Foster Care Children Eligibility: Children receiving Title IV-E foster care maintenance payments who have their eligibility determined according to AFDC eligibility rules that existed on July 16, 1996.

(29) Home and Community Based Services Waiver Program (HCBS): A Medicaid waiver program designed to serve targeted populations in the least restrictive setting as opposed to either a nursing home facility, intermediate care for the intellectually disabled facility, or hospital facilities.

(30) Hospice: A coverage group for terminally ill individuals (or couples) who elect hospice services and who meet all categorical or Medically Needy eligibility criteria and who also meet Medicaid hospice requirements.

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

(32) Household: Spouses, ex-spouses, non-cohabitating partners, persons related by blood or marriage, persons who are presently residing together as a family unit or who have resided together in the past as a family unit, and persons who have a child in common regardless of former or present marital status.

(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 Medicaid program that helps to pay for the cost of care in a nursing facility and provides general medical 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) Medically Needy Coverage Group: Coverage under the Medicaid Program for individuals with gross income that exceeds the applicable Medically Needy Income Levels (MNIL) in Rule 65A-1.716(2), F.A.C.

(40) MEDS-AD Demonstration Waiver: Medicaid coverage group for certain aged or disabled individuals who:

(a) Meet all SSI-related Medicaid non-financial eligibility criteria,

(b) Whose resources do not exceed the limit in the Medically Needy Program,

(c) Whose income is at or below 88 percent of the federal poverty level, and

(d) Are not receiving Medicare or if receiving Medicare are also eligible for Medicaid covered institutional care services, hospice services or home and community based services.

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

(42) Model Waiver: An HCBS waiver program that provides medical services to eligible children under the age of 21 who have degenerative spinocerebellar disease and are living at home. The Model Waiver is a deeming waiver in which parental income is disregarded and the child is considered to be a family of one. The Model Waiver is designed to delay or prevent institutionalization.

(43) Modified Adjusted Gross Income (MAGI): Income that is based on the Internal Revenue Service tax rules and is the adjusted gross income, plus any tax exempt interest and foreign investments excluded from the adjusted gross income.

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

(45) Parent: A father or mother or a person acting as a father or mother.

(46) 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.

(47) 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

(48) Project AIDS Care (PAC): The PAC waiver provides home and community based services to Medicaid eligible persons with a documented diagnosis of AIDS, who choose to live at home.

(49) Qualified Designated Provider.  A qualified designated provider (QDP) is an entity approved to conduct presumptive eligibility determinations for Medicaid for pregnant women.

(50) Qualified Disabled Trust: A trust established by a parent, grandparent, legal guardian, or court on or after October 1, 1993, 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.

(51) 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.

(52) Qualified Noncitizen: An individual who is lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).

(53) 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 disabled individuals 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.

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

(55) Resources: For the SSI-Related Medicaid Program , 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 term “Resources” and “assets” are used interchangeablyin this rule chapter.

(56) 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 enrolled individual or family must incur each month before becoming eligible to receive Medicaid benefits for medical expenses incurred during the remainder of the month.

(57) Sibling: A full, half, or adopted brother or sister who have one or both parents in common.

(58) Spouse: An individual lawfully married to another individual under federal and state law.

(59) Standard Deduction: A base amount of income that is not subject to tax and that can be used to reduce a taxpayer's adjusted gross income (AGI).

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

(61) Statewide Medicaid Managed Care Long Term Care-(SMMC-LTC): A Medicaid waiver that offers statewide long term care managed care program for Medicaid recipients who are 65 years of age or older, or age 18 or older and eligible for Medicaid by reason of a disability; andwho are determined to require nursing facility level of care.

(62) Tax Dependent: An individual for whom another individual claims a deduction for a personal exemption on their tax return.

(63) Tax Dependent Out of the Household (OOTH): An individual not living in the home, whom the tax-filer intends to claim on a tax return.

(64) Tax-Filer: An individual who intends to file a tax return.

(65) 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.

(66) 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.

(67) Traumatic Brain Injury and Spinal Cord Injury (TBI/SCI) Waiver: A home and community based Services (HCBS) Medicaid waiver program for individuals with traumatic brain or spinal cord injuries that offers services that will allow eligible recipients to live at home or in the community and to achieve productive lives to the highest degree possible

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, --------.

 

Substantial rewording of Rule 65A-1.702 follows. See Florida Administrative Code for present text.

65A-1.702 Special Provisions.

(1) Date of Eligibility. The date eligibility for Medicaid begins. Eligibility for Medicaid begins the first day of a month if an individual is eligible any day during the month, except as provided below:

(a)Individuals determined presumptively eligible will receive temporary coverage that begins on the date  the individual is determined presumptively eligible and ends on the last day of the month in which the presumptive eligibility determination was made unless an application for full Medicaid is submitted before the end of the presumptive eligibility period. Presumptive Eligibility for Pregnant Women is determined by a Qualified Designated Provider.

(b) The Department will provide Medicaid to a child if the mother has applied for it, has been determined eligible for it and is receiving Medicaid on the date of the child’s birth. The child is eligible for Medicaid on the date of birth and remains eligible for one year unless one of the following occurs:

1. The child leaves the state,

2. The child dies, or

3.The child no longer resides with the mother.

(c) Individuals applying for the Medically Needy Program become eligible on the date their incurred allowable medical expenses equal the amount of their share of cost (SOC), excluding payments by all third party sources, unless the third party is a public program or a state or a political subdivision of a state and provided, further, that all other factors of eligibility are met. Any medical bill that is unpaid, still owed and has not been used to meet a past  SOC is an allowable medical expense that can be used to meet the individual’s current SOC and shall not be used in future months towards the individual’s future SOC. A medical bill that is incurred and paid during any of the three months before the month of application can be used towards the individual’s SOC for the retroactive months.

(d) Emergency Medicaid for Aliens (EMA) provides Medicaid coverage for noncitizens who qualify for Medicaid except for their citizenship status, and who have a medical emergency.Coverage for individuals eligible for EMA is limited to the duration of the medical emergency. EMA begins the first day of a covered emergency and ends the day following the last day of the emergency medical situation. Documentation of the medical emergency must be obtained from a medical provider. A Medicaid renewal date of 12 months will be assigned. Subsequent medical emergencies require documentation, but the individual will not have to file a new application and the Department will not make a new eligibility determination during this 12 month period. The ineligible noncitizen must meet all Medicaid eligibility requirements except for providing a Social Security Number, cooperating in the pursuit of child support payments, and providing proof of citizenship status.

(e) Enrollment. The enrollment period under the Medically Needy program begins with the month the individual satisfies the non-financial and resource eligibility criteria, if applicable, but not earlier than the third month prior to the month of application.

(2) Processing Medicaid Applications for Supplemental Security Income (SSI) Denials.

(a) The Department will use data obtained from the Social Security Administration’s (SSA) State Data Exchange (SDX) data to identify individuals who have been denied SSI benefits by SSA since August 22, 1996. The date of application for Medicaid eligibility purposes is the date of application for SSI benefits with SSA.

(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 reviewed . These individuals or their SSA payee will be notified in writing to contact the Department within 30 days of the date of the written notice. Failure to do so without good cause, will result in the issuance of written notice of Medicaid denial for failure to follow through in determining eligibility.

(c) Good cause includes severe illness of the individual or a family member, an accident involving the individual or a family member, hospitalization of the individual or a family member, death of the individual or a family member, natural disasters in a relevant geographical area, being away from home or the unexpected closure of a  Department’s office.

(d) Those individuals whom the Department identifies as having an open Medicaid case or a pending Medicaid application at the time the SDX data is reviewed will not be required to contact the Department, unless additional information is needed to complete the eligibility  process. The 30 day deadline for contacting the Department does not apply to these individuals.

(3) Ex Parte Process.

(a) When a recipient’s eligibility for Medicaid ends under one coverage group, the Department must evaluate their eligibility for continued medical assistance under all other available Medicaid coverage group(s) before terminating Medicaid coverage. Both Family-Related Medicaid and SSI-Related Medicaid eligibility are determined based on available information. If additional information is required to make the determination for Family Related Medicaid, the information  can be requested from the recipient. For SSI-Related Medicaid eligibility, the information can be requested from the recipient or SSA. There is no requirement for the individual to contact the Department or file an application to initiate the ex-parte review for continued Medicaid eligibility.

(b) All individuals who lose Medicaid eligibility under one coverage group will continue to receive Medicaid under that coverage group until the ex parte Medicaid renewal process is complete. If the Department determines that the individual is not eligible for any other Medicaid coverage group, the individual may appeal the decision and, unless waived, benefits will be continued if the appeal or request for a hearing is received by the last day of the month prior to the effective date of the termination of Medicaid as stated in the notice. The continuation of such medical assistance will be in effect if pending resolution of the appeal.

(c) Individuals losing eligibility due to income that was calculated based on the Modified Adjusted Gross Income (MAGI) budgeting methodology will be transferred to Children’s Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM), for a determination of eligibility.

(4) Requirement to File for Other Benefits.

(a) As a condition of eligibilityfor Medicaid, the Department requires that an individual apply for any annuity, pension, retirement, disability or Medicare benefits to which they may be entitled.

(b) After the Department notifies an individual that they must apply for the other benefit(s), if the individual fails to do so, they are not eligible for Medicaid.

(5) Child Support Enforcement Cooperation (CSE) . For the purpose of establishing Medicaid eligibility,  a pregnant woman is not required to cooperate with Child Support Enforcement as a condition of eligibility. Cooperation with CSE is also not required child  only Medicaid cases.

(6) Re-evaluating Medicaid Adverse Actions for Individuals who do not Request a Hearing. The Department shall re-evaluate any adverse Medicaid determination upon a showing by the individual that the previous determination was incorrect and that the individual has good cause for not requesting a hearing within the 90 calendar day time period prescribed in Chapter 65-2.046, F.A.C. This provision applies only when benefits were terminated or denied erroneously or the amount of a share of cost or patient responsibility was determined erroneously. A re-evaluation must be requested within 12 months from the effective date of the notice of adverse action.

(a) Good cause for re-evaluating Medicaid adverse actions consists of any of the following:

1. Mathematical Error – The Department made a mechanical, computer or human error in its mathematical computations of resources or income requirements for Medicaid eligibility.

2. Records Error – The Department made an error in a Medicaid determination which caused an incorrect decision. For example, there is evidence showing that the individual’s resources satisfied Florida’s standard of eligibility but the application was denied on the basis of excess resources.

3. New and Material Evidence – The  Department’s determination was correct when made but new and material evidence that the Department did not previously consider establishes that a different decision should be made.

(b) Failure of the individual to provide information required by the Department to accurately determine eligibility for Medicaid where the failure was beyond the individual’s control constitutes good cause for re-evaluation. However, if the individual fails to cooperate with the Department in establishing eligibility, good cause for re-evaluation does not exist.

(c) Good cause, for purposes of subsection (6), includes severe illness of the individual or a family member, an accident involving the individual or a family member, hospitalization of the individual or a family member, death of the individual, death of a family member, natural disasters, being away from home, or unexpected closure of a Department’s offices

(d) The Economic Self Sufficiency Specialist (ESSS) is responsible for the initial determination of good cause.  The decision must, automatically, be reviewed by the ESSS’s supervisor. If both the ESSS and the ESSS’s supervisor determine that good cause does not exist, the next level administrator, in consultation with the Regional Program Office Administrator, must automatically review the decision. If a determination is made by the Regional Program Administrator that good cause does not exist, the individual will be notified of the decision and of the right to appeal or request a hearing.

(e) If a case is re-opened and the Department discovers that an error was made in the eligibility determination, benefits must be provided retroactively as follows:

1. If an application was denied, benefits will be awarded back to the date of application, provided all other eligibility requirements are met.

2. If an ongoing case was terminated, benefits will be awarded back to the effective date of the termination provided all other eligibility requirements are met.

(f) If re-evaluation of the previous decision results in adverse action, the individual has 90 calendar days from the date of notice of disposition of the re-opened case to request a hearing. If at the end of 90 calendar days a hearing is not requested, the disposition of the re-opened case will be final and binding upon the individual. (7) Assignment of Rights to Benefits. Each individual applying for or receiving Medicaid must cooperate with the Department in its efforts to secure receipt of medical support and payments from third parties that are otherwise due to the individual, unless good cause exists for not cooperating. Good cause exists when the individual previously applied for and was denied third party benefits or medical support, and the reason for denial has not changed.

(8) Retroactive Medicaid. Retroactive Medicaid is based on an approved, denied, or pending application for ongoing Medicaid benefits.

(a) Retroactive Medicaid eligibility is not effective before the third month prior to the month of application. The individual must meet all Medicaid eligibilityrequirements during the retroactive months. A request for retroactive Medicaid can be made for a deceased individual by a designated representative or caretaker relative, by filing a medical assistance application . However, Qualified Medicare Beneficiaries (QMB’s) are not eligible for retroactive Medicaid benefits under the QMB coverage group as indicated in Title XIX of the Social-Security Act § 1902(e)(8).

(b) SSI Cash Assistance Recipients. Upon SSI approval, all SSI recipients receive a system-generated notice of potential entitlement for retroactive Medicaid benefits and a reply card to be returned to the Department if the SSI recipient is interested in receiving retroactive Medicaid benefits. If the SSI recipient or their designated representative or caretaker relative, contacts the Department or returns the reply card, the Department will proceed with an eligibility determination, including contacting the SSI recipient to request additional information or conducting a telephone interview with the SSI recipient, the designated representative, or caretaker relative.

(9) Re-Enrollment. In order for an individual or family to be eligible for re-enrollment in the Medically Needy program, they must:

(a) Continue to satisfy the resource criteria,if applicable;

(b) Continue to satisfy all non-financial eligibility criteria;and

(c) Provide verifications as needed. The re-enrollment period may exceed 12 months when there is a delay in the Department’s processing of the re-enrollment.

(10) Limits of Coverage.

(a) Qualified Medicare Beneficiary (QMB). Under QMB coverage, individuals are eligible for Medicare cost-sharing benefits, including payment of Medicare premiums.

(b) Special Low-Income Medicare Beneficiary (SLMB). Under SLMB coverage, individuals are eligible for payment of the Part B Medicare premium. If eligible, AHCA will pay the premium for up to 3 months retroactive to the month of application.

(c) Working Disabled (WD). Under WD coverage, individuals are eligible for payment of their Medicare Part A premium.

(d) Qualifying Individuals-1 (QI-1). Under QI-1 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.)

(11) Determining Share of Cost (SOC). The SOC is determined by deducting the appropriate Medically Needy Income Level from the individual’s or family’s income.

(12) Eligibility of SSI Cash Assistance Recipients. Eligible SSI recipients who are residents of Florida are automatically eligible for Medicaid pursuant to 42 CFR § 435.120 .(13)Trusts.

(a) The Department applies trust provisions set forth in §1902 of the Social-Security Act.

(b) Funds transferred into a trust or other similar device established other than by a will prior to October 1, 1993 by the individual, a spouse or a legal representative are available resources if the trust is revocable or if the trustee has any discretion over the distribution of the principal. Such funds are a transfer of a resource or income, if the trust is irrevocable and the trustee does not have discretion over distribution of the corpus,or if the individual is not the beneficiary. No penalty can be imposed when the transfer occurs beyond the 60 month look-back period. Any disbursements which can be made from the trust to the individual or to someone else on the individual’s behalf shall be considered available income to the individual. Any language which limits the authority of a trustee to distribute funds from a trust, if such distribution would disqualify an individual from participation in government programs, including Medicaid, shall be disregarded.

(c) Funds transferred into a trust, other than a trust specified in 42 U.S.C. § 1396p(d)(4), by a person or entity specified in 42 U.S.C. § 1396p(d)(2) on or after October 1, 1993 shall be considered available resources or income to the individual in accordance with 42 U.S.C. § 1396p(d)(3) if there are any circumstances under which disbursement of funds from the trust could be made to the individual or to someone else for the benefit of the individual. If no disbursement can be made to the individual or to someone else on behalf of the individual, the establishment of the trust shall be considered a transfer of resources or income.

(d) The trustee of a qualified income trust, qualified disabled trust or a pooled trust, shall provide quarterly statements to the Department which identify all deposits to and disbursements from the trust for each month during the eligibility period.

(e) Undue Hardship. A period of ineligibility shall not be imposed if the Department determines that the denial of eligibility based on counting funds in an irrevocable trust according to provisions in paragraphs 65A-1.702(15), F.A.C., would create an undue hardship on the individual. Undue hardship exists when application of a trust policy would deprive an individual of food, clothing, shelter or medical care such that their life or health would be endangered. This can be caused by legal restrictions or by illegal actions of a trustee. All efforts by the individual, or their legal spouse or representative to access the resources or income must be exhausted before this exception applies.

(14) Statewide Inpatient Psychiatric Program (SIPP). SIPP is for Medicaid eligible children under the age of 21 who require a residential level of care for treatment of a serious emotional disturbance. Those who are Medically Needy and those who are Medicare recipients are excluded from this program. Services must be received from a designated SIPP provider selected by the Agency for Health Care Administration (AHCA). SIPP providers must be licensed as a hospital or residential treatment center for children and adolescents by AHCA.This program provides an exception to provisions that residents of an institution for mental disease (IMD) are not eligible for Medicaid.

Rulemaking Authority 409.919 FS. Law Implemented 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 4-22-98, 2-15-01, 9-24-01, 11-23-04, 5-31-06, 8-10-06,       .

 

Substantial rewording of Rule 65A-1.703 follows. See Florida Administrative Code for present text.

65A-1.703 Family-Related Medicaid Coverage Groups.

The Department determines eligibility for mandatory and optional Medicaid coverage groups for individuals, families and children described in “The Patient Protection and Affordable Care Act”, (Public Law 111-148, enacted on March 23, 2010), “The Health Care and Education Reconciliation Act of 2010”, (Public Law 111-152, enacted on March 30, 2010), the Florida Medicaid Program under Title XIX of the Social Security Act, 42 U.S.C. section 1396a(a)(10), the Children Health Insurance Program under Title XXI of the Social Security Act, 42 U.S.C. section 1397bb(a)(1), and s. 409.903, F.S. For coverage groups, the following additional information apply:

(1) For children under 21 years of age, the child must either be living on their ownor with aparent or caretaker relativeand their spouse, and meet the eligibility criteria of Title XIX section 1902(1)(10)(A)(i)(VII) of the Social Security Act.

(2) For children for whom the Department is assuming full or partial financial responsibility, the child must be:

(a) .Placed in either a family foster home, or an approved adoptive home by a child-placing agency, or the child must be placed with a residential child caring agency;

(b). In an independent living facility;

(c). In a licensed emergency shelter home; or

(d) In a publicly operated community residential facility.

(3) Parents, caretaker relatives, and their spouse derive their eligibility from a child residing with them who is under 18, never married, and who is not emancipated, provided their household income is equal to or below the income limit established in the Medicaid State Plan for the coverage group.

The income limit or standard 19 percent of the federal poverty level (FPL) converted to the modified adjusted gross income (MAGI) equivalent FPL. There is no asset limit.

(4) Children placed for adoption and adopted children.

(a) 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 that:

1. The child has a pre-existing special need for medical or rehabilitative care that would have precluded adoption placement without receipt of Medicaid under the Florida Medicaid State Plan; and

2. Prior to execution of the adoption assistance agreement, the child:

a. Was receiving, or was eligible to receive, Medicaid, or

b. Would have been eligible for Medicaid if the Title IV-E financial requirements specified in. 42 U.S.C section 473, had been used to determine Medicaid eligibility.

(b) Children placed for adoption. Children under the age of 18 for whom there is a state adoption assistance agreements under Title IV-E of the Social Security Act in effect are deemed eligible for Medicaid even if assistance payments are not being made. If an adoption assistance agreement is in effect, Medicaid eligibility begins when the child is placed for adoption according to state law even if an interlocutory or final judicial decree of adoption has not been issued.

(5) Medicaid for children under age 19. To be eligible for this coverage group the child must meet the general requirements specified in Rule 65A-1.705, F.A.C. The following additional eligibility criteria apply:

(a) There is no asset limit;

(b). The total net income for the household of a child under age 1 must be less than or equal to 185 percent of the MAGI converted FPL and;

(c). The total net income for age 1 but less than age 19 is less than or equal to 133 percent of the  MAGI converted FPL.

(6) Medicaid for pregnant women. To be eligible for this coverage group an expecting mother a woman must meet the eligibility requirements specified in Rule 65A-1.705, F.A.C. The following additional eligibility criteria apply:

(a) There is no asset limit;

(b) The total income of the household is at or below 185 percent of the MAGI converted FPL;(c) When eligibility is based solely on a pregnancy, the Department will

(d) Eligibility is extended for 60 days after the pregnancy ends and any remaining days in the month in which the 60th day falls regardless of changes in the woman’s financial circumstances that may occur within this extended 60-day period. At the end of the extended period an ex parte determination must be completed and the individual notified of any changes in eligibility

(e) The expecting mother is not required to comply with child support enforcement requirements.

(7) Medicaid for children ages 19 to 21: The total net income for the household of a child age 19 to 21 must be less than or equal to 19 percent of the MAGI converted FPL.

(8) Former foster care individuals who are:

(a) Under age 26,

(b) In the Florida foster care system on their 18th birthday, and

(c) Receiving full Medicaid when they aged out of foster care.

(d) There is no income limit; and

(e) There is no asset limit.

(9) Medically Needy. To be eligible for this coverage group the individual must meet the eligibility requirements prescribed in Rule 65A-1.705, F.A.C.

(a) Included in this coverage group are the following groups of individuals:

1. Children under age 21 living with a specified relative.

2. Pregnant women.

3. Children in foster care or in adoption subsidy.

4. Parents, caretaker relatives, and their spouse if they are living together.

(b) The following provisions apply to Medically Needy: The individual must have income at or below the respective Medically Needy Income Limit set forth in 65A-1.716(2), F.A.C. If income exceeds the Medically Needy Income Limits refer to subparagraph 65A-1.707(2), F.A.C. Refer to Rule 65A-1.713(1)(h), F.A.C., for additional income criteria applicable to the Medically Needy Program.

Rulemaking Authority 409.919 FS. Law Implemented 409.1451(5)(b), (7), 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 9-28-98, 2-15-01, 6-13-04,        .

 

Substantial rewording of Rule 65A-1.705 follows. See Florida Administrative Code for present text.

65A-1.705 Family-Related Medicaid General Eligibility Criteria.

(1) The Family-Related Medicaid technical eligibility factors

(a) The age criteria for children is specified in rule 65A-1.703, F.A.C.

(b) The individual must be a resident of Florida as required by subsection 1902(a)(16) of the Social Security Act (2007), incorporated by reference. Individuals who are physically present in Florida on a temporary basis may be considered residents of the State on a case-by-case basis if they indicate an intent to reside in Florida.

(c) The individual must be a citizen of the United States, or a qualified non-citizen as defined in rule 65A-1.701(51) F.A.C.

(d) The identity of each U.S. citizen, or qualified non-citizen, applying for or receiving Medicaid must be documented and verified.

(e) A standard filing unit (SFU) is determined for each individual being tested for eligibility.  An SFU is the tax filing group for the tax year in which eligibility is being determined. An SFU is determined as follows:

1. If the individual expects to file a tax return for the tax year in which eligibility is being determined and they do not expect to be claimed as a tax dependent by someone else, the SFU will consist of the individual, the individual’s spouse,if any and all claimed tax dependents of the individual. The living arrangements of a spouse or tax dependent is not material to the compostion of the SFU.

2. If the individual expects to be claimed as a tax dependent by someone else for the tax year in which eligibility is being tested, the SFU is the individual, the individual’s spouse, if any, the tax filer, the tax filer’s spouse , if any, and all claimed tax dependents of the tax filer, including individuals claimed as dependent. The living arrangement of a spouse or tax dependent is not material to the composition of the SFU. The following exceptions will apply and the individual will not be included in the tax filing group:

a. If the individual is claimed as a tax dependent by someone other than the parent (natural, adopted, or stepparent);

b. If the individual is a child living with both parents who expect to file separate tax returns and only one parent claims the child as a dependent; or

c. If the individual is a child who is claimed as a tax dependent by a non-custodial parent.

3. If the individual does not expect to file a tax return and is not claimed as a tax dependent on someone else’s tax return, the SFU is the individual, the individual’s spouse (if living together), and the individual’s children (biological, adopted, and stepchild[ren]) that are under the age of 19, or the children age 19 or 20, and enrolled in school full time. If the individual is a child, the SFU is the child’s parents, (biological, adopted, and stepparent) living with the child and any siblings (biological, adopted, and step siblings) that are under the age of 19, or who are age 19 or 20 and enrolled in school full time4. The needs and income, with the exception of SSI income,of individuals who receive only SSI-Related Medicaid under subsections 1619(a) and (b) of the Social Security Act (2007), incorporated by reference, are counted when determining the eligibility of the SFU.

5. Individuals who are ineligible on the factor of citizenship must be included in the SFU subject to tax filer or non-tax filer rules even though the individual is not eligible to receive medical assistance.

Rulemaking Authority, 409.919 FS. Law Implemented , 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 9-28-98, 4-5-99, 11-23-99, 2-15-01, 9-24-01, 4-1-03, 6-26-08, 9-16-08,        .

 

Substantial rewording of Rule 65A-1.716 follows. See Florida Administrative Code for present text.

 

65A-1.716 Income and Resource Criteria.

(1) The monthly federal poverty level figures based on the family size are as follows:

Family Size				133% of Poverty Level
1		$973		$1,294		$1,800	$1,945
2		$1,311		$1,744		$2,426	$2,622
3		$1,650		$2,194		$3,051	$3,299
4		$1,988		$2,644		$3,677	$3,975
5		$2,326		$3,094		$4,303	$4,652
6		$2,665		$3,544		$4,929	$5,329
7		$3,003		$3,994		$5,555	$6,005
8		$3,341		$4,444		$6,181	$6,682
9		$3,680		$4,894		$6,807	$7,359
10		$4,018		$5,344		$7,433	$8,035
11				$5,794		$8,059	$8,712
12		$4,695		$6,244		$8,685	$9,389
For each addtl. person		$339		$450		$626	$677

 

(2) Monthly income levels for Family-Related and SSI (Supplemental Security Income)-Related Medically Needy Income Levels (MNIL) are by family size as follows:

Family Size	Monthly Income Level	Family Related MNIL	SSI-Related MNIL
1	$180	$289	$180
2	$241	$387	$241
3	$303	$486
4	$364	$585
5	$426	$684
6	$487	$783
7	$549	$882
8	$610	$981
9	$671	1079
10	$733	1179
Add for each addtl. person :	$62	$100

Exception: In determining eligibility for a pregnant woman, the income limits for Monthly Income Level and MNIL used shall be increased to the higher limit corresponding to the applicant’s actual family size.  Family size shall include each anticipated unborn child as a family member.

(3) The resource limits for the Medically Needy program are as follows:

(a) Family-Related Medicaid: $0

(b) SSI-Related Medicaid:

1. $5,000 per individual; and

2. $6,000 per couple

	Monthly
Family	Asset
Size	Level
1	$5,000
2	$6,000
3	$6,000
4	$6,500
5	$7,000
6	$7,500
7	$8,000
8	$8,500
9	$9,000
10	$9,500

For each additional person add $500.

Exception: In determining eligibility for a pregnant woman the resource limit used shall be increased to the higher limit corresponding to the applicant’s actual family size, including each anticipated unborn child as a family member.

(4) The maximum resource limit is $2,000 for those individuals:

(a) Whose Medicaid coverage is based on payment standard income criteria Refer to rule 65A-1.716(2), F.A.C.; or

(b) Are children living with their parent(s) and who, as children, would qualify for cash assistance except for their age. The maximum resource limit of $2,000 also applies to those coverage groups indicated in rule 65A-1.703, F.A.C. However, there is no asset limit for the coverage groups specified in rule 65A-1.703(3) through (5), F.A.C.

(5) The SSI-Related Medicaid Program Standards:

(a) SSI (42 U.S.C. §§ 1382 – 1383c) Resource Limits:

1. $2000 per individual.

2. $3000 per eligible couple, or per eligible individual with an ineligible spouse who is living together.

(b) The income limit which applies to an individual in Home and Community Based Services (HCBS) waiver programs, Institutional Care Programs (ICP), and Hospice is 300 percent of the Federal Benefit Rate (FBR) for an individual.

(c) Spousal Impoverishment Standards.

1. Resource Allocation . The amount of the couple’s total countable resources which may be allocated to the community spouse of an institutionalized person is equal to the maximum allowed by 42 U.S.C. § 1396r-5(f)(2)(A).

2. Minimum Monthly Maintenance Needs Allowance (MMMNA). The minimum monthly maintenance needs  allowance the Department recognizes for a community spouse is equal to 150 percent of the federal poverty level (FPL) for a family of two as set forth in 42 U.S.C. § 1396r-5(d)(3)(A)(i) and (ii).

3. Excess Shelter Allowance. The community spouse’s shelter expenses must exceed 30 percent of the MMMNA  to be considered excess shelter expenses to be included in the maximum income allowance: MMMNA × 30% = Excess Shelter Allowance as defined in 42 U.S.C. § 1396r-5(3)(A)(ii) and (4)(A)(B). This standard changes July 1 of each calendar year.

4. Food Assistance Program Standard Utility Allowance. The amount specified in Rule 65A-1.603(2), F.A.C.

5. Cap of Community Spouse Needs Allowance. The MMMNA plus excess shelter allowance cannot exceed the maximum amount allowed under 42 U.S.C. § 1396r-5(d)(3)(A)(C). This needs allowance changes January 1 of each year.

(d) The average monthly private pay nursing facility rate is $8,346 .

(e) The following life expectancy tables are compiled from information published by the Office of the Chief Actuary of the Social Security Administration:

FEMALE LIFE EXPECTANCY TABLE
Aged	Life Expectancy	Age	Life Expectancy	Age	Life Expectancy
0	80.43	40	41.91	80	9.43
1	79.92	41	40.97	81	8.86
2	78.95	42	40.03	82	8.31
3	77.97	43	39.10	83	7.77
4	76.99	44	38.17	84	7.26
5	76.00	45	37.24	85	6.77
6	75.01	46	36.32	86	6.31
7	74.02	47	35.41	87	5.87
8	73.03	48	34.50	88	5.45
9	72.04	49	33.59	89	5.06
10	71.04	50	32.69	90	4.69
11	70.05	51	31.80	91	4.36
12	69.06	52	30.91	92	4.04
13	68.07	53	30.02	93	3.76
14	67.08	54	29.14	94	3.50
15	66.09	55	28.27	95	3.26
16	65.11	56	27.40	96	3.05
17	64.13	57	26.53	97	2.87
18	63.15	58	25.67	98	2.70
19	62.18	59	24.82	99	2.54
20	61.20	60	23.97	100	2.39
21	60.23	61	23.14	101	2.25
22	59.26	62	22.31	102	2.11
23	58.29	63	21.49	103	1.98
24	57.32	64	20.69	104	1.86
25	56.35	65	19.89	105	1.74
26	55.38	66	19.10	106	1.62
27	54.40	67	18.32	107	1.52
28	53.44	68	17.55	108	1.41
29	52.47	69	16.79	109	1.31
30	51.50	70	16.05	110	1.22
31	50.53	71	15.32	111	1.13
32	49.56	72	14.61	112	1.05
33	48.60	73	13.91	113	0.97
34	47.64	74	13.22	114	0.89
35	46.68	75	12.55	115	0.82
36	45.72	76	11.90	116	0.75
37	44.76	77	11.26	117	0.70
38	43.81	78	10.63	118	0.64
39	42.86	79	10.03	119	0.59
MALE LIFE EXPECTANCY TABLE
Age	Life Expectancy	Age	Life Expectancy	Age	Life Expectancy
0	75.38	40	37.84	80	7.90
1	74.94	41	36.93	81	7.41
2	73.98	42	36.02	82	6.94
3	73.00	43	35.12	83	6.49
4	72.02	44	34.22	84	6.06
5		45		85
6		46		86
7		47		87
8		48		88	4.55
9		49		89
10		50		90
11		51		91
12		52		92
13		53		93
14		54		94
15		55		95
16		56		96
17		57		97
18		58		98
19		59		99
20		60		100
21		61		101
22		62		102
23		63		103
24		64		104
25		65		105
26		66		106
27		67		107
28		68		108
29		69		109
30		70		110
31		71		111
32		72		112
33		73		113
34		74		114
35		75		115
36		76		116
37		77		117
38		78		118	0.64
39		79		119	0.59

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History–New 10-8-97, Amended 12-9-99, 2-15-01, 11-25-01, 7-28-02, 4-1-03, 9-10-03, 8-30-04, 8-10-06, 4-15-12, 10-16-12, 11-4-12, 9-18-13,        .

 

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: September 5, 2013