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”, under “The Health Care and Education Reconciliation Act 2010”, Section 1931 of the Social Security Act, relevant provisions of the Medicaid Program under Title XIX of the Social Security Act, the Children’s Health Insurance Program under Title XXI of the Social Security Act and Section 409.903. F.S.

(1) The mandatory and optional Family-Related coverage groups are stated in each subsection of this rule that are entitled to coverage under the Florida Medicaid Program:

(a) Children under age 19.

(b) Children age 19 to 21.

(c) Children in foster care.

(d) Children placed for adoption and adopted children.

(e) Former foster care individuals up to age 26.

(f) Parents and caretaker relatives of children.

(g) Pregnant women.

(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 Rule 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. The standard disregard is applied for a child under age one, children age 1-5.

2. The countable net income for the filing unit/family size of a child under age one must be less than or equal to 200 percent of the FPL.

3. The countable net income for the filing unit/family size of a child age one and up to age 19 is less than or equal to 133 percent of the FPL.

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 Medicaid State Plan. 

5. To determine eligibility for a pregnant woman, the filing unit shall include each anticipated unborn child as a family member including the pregnant woman.

(b) Children in Foster Care. Children for whom the Department is assuming full or partial responsibility, the child must be:

1. Placed in either a foster home, a home of a relative or nonrelative, or an approved adoptive home by a child-placing agency, or the child must be placed with a residential child care agency; or

2. In an independent living facility; or

3. In a licensed emergency shelter home; or

4. In a publicly operated community residential facility.

(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 Medicaid State Plan, and

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

I. Was receiving or was eligible to receive Medicaid or

II. Would have been eligible for Medicaid if the Title IV-E financial requirements specified in 42 U.S.C. §473(2)(A), had been used to determine Medicaid eligibility.

2. Children placed for adoption. Children under the age of 18 for whom there is a state adoption assistance agreement under Title IV-E of the Social Security Act in effect are deemed eligible for Medicaid even if the 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 or adoption has not been issued.

(d) Former foster care individuals who are:

1. Under age 26.

2. In the Florida foster care system on their 18th birthday and receiving full Medicaid when they aged out of foster care.

3. There is no income or resource limit.

4. Not eligible and enrolled for other Medicaid mandatory coverage groups.

(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 Florida’s Medicaid State Plan for the coverage group. The fifth degree of relationships includes the following individuals:

1. Brother, sisters (including step and those of half-blood),

2. Aunts, uncles, nieces and nephews,

3. First cousins (first cousins once removed), and

4. Individuals of preceding generations as denoted by prefix of “grand”, “great”, “great-great”, “great-great-great”, etc.

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

1. The countable net income of the filing unit/family size is at or below 185 percent of the FPL.

2. When eligibility is based solely on a pregnancy, the Department will accept the individual’s attestation of the number of expected births.

3. The expectant mother is not required to comply with Child Support Enforcement requirements.

4. Eligibility is extended through the month of birth and the two post-partum months regardless of changes in the income for the filing unit/family size. At the end of the extended period, an ex-parte determination must be completed and the individual notified of any changes in eligibility.

(3) 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 individuals:

1. Children under age 21,

2. A parent or caretaker relative and their spouse if living together with a child up to age 19, within the fifth degree of the specified relationships:

a. Brother, sisters (including step and those of half-blood),

b. Aunts, uncles, nieces and nephews,

c. First cousins (first cousins once removed),

d. Individuals of preceding generations as denoted by prefix of “grand”, “great”, “great-great”, “great-great-great”, etc.,

e. The natural and other legally adopted children and other relatives of the adoptive parents, if they are within the specified degree, and

f. Legal spouses of any person’s names in the above groups.

3. Pregnant Women, and

4. Children in foster care or receiving an adoption subsidy.

(b) The following provisions apply to Medically Needy:

1. The individual must have income at or below the respective Medically Needy Income Limit set forth in subsection 65A-1.716(2), F.A.C. If income exceeds the Medically Needy Income Limits refer to subsection 65A-1.707(9), F.A.C. Refer to paragraph 65A-1.713(1)(h), F.A.C. for additional income criteria applicable to the Medically Needy Program.

2. There is no asset or resource limit.

Rulemaking Authority 409.1451, 409.919 FS. Law Implemented 409.903, 409.904, 409.919 FS. History–New 10-8-97, Amended 9-28-98, 2-15-01, 6-13-04, 3-25-20.