What is Florida’s Medically Needy Program, and How Does it Work?

With the implementation of the Affordable Care Act, many states have enacted laws expanding Medicaid coverage by offering insurance to more people than were previously eligible. However, not all states participate in Medicaid expansion. Florida remains one of several states that have opted out of expansion; therefore, it is very difficult for adults to receive Medicaid coverage. Many adults in the state fall into a coverage gap, meaning the make too much to qualify for Medicaid, yet too little to reasonably afford Marketplace coverage without a tax subsidy. The Medically Needy program (also called “share of cost”) is designed in part to ease the burden this places on lower income Floridians. Here is how it works.

What is the Medically Needy Program?

For those who make too much to be eligible for traditional Medicaid in Florida, the Medically Needy program is based on family size and household income and sets forth the maximum amount you must spend on healthcare in a given month. The program basically allows the state to share in the cost of your care each month, but only once you meet a certain “out-of-pocket” amount. In fact, it acts a lot like a deductible in many ways. Consider the following example.

EXAMPLE

Say you qualify for the Medically Needy program and are determined eligible for a maximum share of cost of $1,000. On March 10, you go to the emergency room and incur a bill for $800, and then on March 15, you have a follow-up appointment with your doctor, along with several prescriptions. The total for the appointment and medications is $200. You have now met your share of cost for March. Any further expenses in this month are fully covered by Medicaid. However, on April 1, you start over again.

But it’s not really a deductible at all

While the Medically Needy program does set forth an amount you must incur before Medicaid will kick in to pay for your care, unlike a typical deductible, you do not actually have to pay any part of your bills in a given month that you meet the share of cost amount. In other words, in our example above, you would not have to pay $1,000 before Medicaid picks up the bill; you simply must incur bills that total that amount. So Medicaid is not just paying the amount after $1,000; it is paying the whole amount, including $1,000 and anything beyond that.

Does the Medically Needy program take care of the nursing home bill?

Maybe. This is a difficult question to answer without fully reviewing one’s full financial picture. Medicaid rules are complicated and involve assessing all of one’s income, retirement assets, savings, and healthcare picture. In some cases, you may qualify for full Medicaid coverage, even if you have significant assets and income. The key is advanced planning.

If you or someone in your family is facing retirement or a possible nursing home placement in central Florida, contact the Millhorn Elder Law Planning Group for assistance. We are eager to help you however possible.