Understanding Medicaid Programs

Medicaid is a federal program administered by each state that provides assistance to low-income individuals who meet the eligibility criteria set by that state. In Florida eligibility is based on age or disability according to Social Security Standards and on income and asset limits. Financial eligibility changes annually and varies by program. Apply on the internet at http://www.myflorida.com/accessflorida/. Full Medicaid benefits provide a variety of health services, but they must be obtained from providers who are certified to accept payment from Medicaid. Individuals who have Medicare may also have Medicaid, but Medicaid will only pay for services after Medicare has paid. For prescription drug coverage, individuals with Medicare must enroll in the Medicare Part D Prescription Drug Plan.

Programs that provide full Medicaid benefits include:

Supplemental Security Income (SSI) recipients - SSI is administered by the Social Security Administration and provides financial assistance to needy persons age 65 and over and to needy blind and disabled persons. Individuals who meet receive SSI through Social Security are automatically eligible to receive Medicaid in Florida. SSI eligibility requirement as of March 2008: Individual gross monthly income of $637 and asset limit = $2,000. Couple gross monthly income of $956 and asset limit is $3,000.

MEDS for Aged and Disabled (MEDS- AD) - This program changed 1/1/2006 and now serves a limited group of those age 65+ or disabled who meet income and asset criteria and do not have Medicare A or B. It also serves clients who are in other Medicaid programs. Eligibility requirement as of March 2008: Individual gross monthly income of $763 and asset limit = $5,000. Couple gross monthly income of $1027 and asset limit = $6,000.

Institutional Care Program (ICP) - ICP helps people age 65+ or disabled and in nursing facilities pay for cost of their care plus provides general medical coverage. Must meet level-of-care as determined by the Department of Elder Affairs CARES Unit. There may be financial responsibility for the patient and eligibility may involve an Income Trust. Financial eligibility requirement as of March 2008: Individual gross monthly income of $1,911 and asset limit = $2,000. Couple gross monthly income of $3,822 and asset limit = $3,000 if both persons are being deemed eligible. For ICP, when one person is going into a nursing home, then the community spouse is allowed to retain income and assets in excess of this amount.

Aged Disabled Adult Waiver Program (ADA Waiver) - Provides home and community-based services for individuals 60 years of age or older or disabled persons age 18 - 59 who are in need of nursing home care who could remain at home if provided special services. These individuals must meet ICP financial criteria and must meet a level-of-care as determined by the Department of Elder Affairs CARES Unit. Funding for this program is limited and not everyone who applies will receive services. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Assisted Living for the Elderly Program (ALE Waiver) - Provides home and community-based services for individuals aged 65+ or aged 60+ and disabled who reside in qualified Assisted Living Facilities (ALF). Must meet ICP financial criteria and must meet a level-of-care as determined by the Department of Elder Affairs CARES Unit. Funding for this program is limited and not everyone who applies will receive services. This program does not pay the room and board costs of ALF care. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Long Term Care Diversion Program Waiver Program - A program for individuals age 65 and over who need nursing home care and meet financial and functional requirements. Services are provided through a managed care provider (HMO). If the individual chooses the managed care option, the HMO will manage the individual?s medical needs regardless of their living situation?home, ALF, or nursing home. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Hospice - Provides Medicaid services for terminally ill persons. Apply through a local Hospice. Financial eligibility is the same at the Institutional Care Program (ICP). See above.

Developmental Services Waiver Program (DS Waiver) - Prevents institutionalization by allowing individuals age 3 and over with developmental disabilities to remain at home in the community. Financial eligibility is the same at the Institutional Care Program (ICP). See above. Funding for this program is limited and not everyone who applies will receive services. Contact the Agency for Persons with Disabilities for information.

Project AIDS Care Waiver Program (PAC Waiver) - Provides home and community based services for individuals who are age 65+ or disabled and who have a diagnosis of AIDS. Financial eligibility is the same at the Institutional Care Program (ICP). See above. Funding for this program is limited and not everyone who applies will receive services.

Cystic Fibrosis Waiver Program ( CF Waiver) - Provides home and community-based services for individuals age 18 and over who are diagnosed with cystic fibrosis, require hospitalization but could remain at home if provided special services. Financial eligibility is the same at the Institutional Care Program (ICP). See above. Funding for this program is limited and not everyone who applies will receive services.

Medicaid Programs that have limited Medicaid benefits include:

Medically Needy - Provides Medicaid for persons with high medical bills but who are not eligible for Medicaid because their income or assets are too high. Those enrolled in this program must incur a certain amount of medical bills each month, which is known as ?share of cost?. This amount is based on income and household size. Once the share of cost is reached, the DCF can approve full Medicaid benefits for the remainder of that month only. Medicaid does not cover the costs of prescription drugs for Medicare recipients who must now use the Medicare Part D prescription coverage.

Qualified Medicare Beneficiary (QMB) - Individuals who qualify for QMB are eligible to have Medicaid pay for Medicare Premiums for Parts A and B, Medicare deductibles, and Medicare coinsurance within the prescribed limits. This is the only Medicaid benefit. Eligibility requirement as of March 2008: Individual gross monthly income of $867 and asset limit = $5,000. Couple gross monthly income of $1,167 and asset limit = $6,000.

Special Low Income Medicare Beneficiary (SLMB) - Individuals who are eligible for SLMB are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. This is the only Medicaid benefit. Eligibility requirement as of March 2008: Individual gross monthly income of $1,040 and asset limit = $5,000. Couple gross monthly income of $1,400 and asset limit = $6,000.

Qualified Individuals (QI-1) - Individuals who are eligible for QI1are eligible to have Medicaid pay Medicare directly for Medicare premiums for Part B. The income limits are higher than SLMB and payment is only guaranteed through the end of the year the application was made. This is the only Medicaid benefit. Eligibility requirement as of March 2008: Individual gross monthly income of $1,170 and asset limit = $5,000. Couple gross monthly income of $1,575 and asset limit = $6,000.

All full Medicaid recipients and QMB, SLMB and QI-1 beneficiaries are automatically entitled to extra help with Medicare Prescription Drug Plan costs. This is also known as Low Income Subsidy (LIS) and it pays all or most of the annual deductible, provides coverage during the gap period, and pays the monthly premium up to a base amount. Co-pays are the responsibility of the individual. Without Medicaid the LIS eligibility requirement as of 2008: Individual gross monthly income of $1,300 and asset limit = $10,490. Couple gross monthly income of $1,750 and asset limit = $20,970.

Medicaid has complex programs. The eligibility requirements mentioned above are meant to provide basic information only and do not include detailed information that should be obtained through DCF. The Fact Sheet is for information purposes and is not a legally binding document.

Source: SSI Fact Sheet and the March 2008 ?SSI Related Programs ?Financial Eligibility Standards? compiled by the Florida Department of Children and Families (DCF).
Updated March 2008

Note:
Some March 2008 income limits are lower than they were in January 2008, and some individuals who were eligible under the January 2008 limits are no longer eligible since the requirements are $1 to $5 lower.

Go to http://www.dcf.state.fl.us/ess/ssi_fin_elig_chart.pdf

or to http://www.dcf.state.fl.us/ess/ssifactsheet.pdf

for more information.