Florida Medicaid

A Reference Guide

The Florida Agency for Health Care Administration (AHCA) is designated as the chief health policy and planning entity for the state and licenses and regulates health care facilities and health maintenance organizations (HMOs) across the state. AHCA also administers the Florida Medicaid program that provides health care to Florida’s low-income and disabled citizens. AHCA’s mission is to champion accessible, affordable, quality health care for all Floridians. To help achieve this mission, AHCA publishes the Consumer Awareness Series. This series consists of brochures designed to assist the public in making well-informed health care decisions.

This brochure provides general information about the Florida Medicaid program.
Note: This brochure is not designed to offer medical or legal advice. Please consult with your physician for medical advice and an attorney for legal advice.
Information in this brochure is current as of September 2007.

The Florida Medicaid Program

The Florida Medicaid program provides medical coverage for Florida residents who meet the program’s low-income eligibility requirement. This mostly includes children, pregnant women, disabled adults, and seniors.
The program is funded by state and federal funds, with counties contributing to the cost of inpatient hospital care and nursing home services.

Medicaid is different in every state. The federal government sets the general guidelines and designates certain services every state must offer and optional services that are not required, but may be offered if a state chooses.

Many Medicaid beneficiaries in Florida are enrolled in some form of health plan, which includes MediPass, health maintenance organizations, provider service networks, and local provider organizations. Individuals choose among the health plans available in their area of the state and see health care providers who are a part of the plan.

For further information on Medicaid health plans, call the Medicaid Options toll-free number (888) 367-6554 (or TDD 800-653-9803), or view the website www.MedicaidOptions.net. Medicaid recipients who live in Baker, Broward, Clay, Duval, or Nassau County can call the Medicaid Choice Counseling Helpline toll-free number (866) 454-3959 (or TDD 866-467-4970).

Beneficiaries who aren’t required to enroll in a health plan may continue to obtain services from any Medicaid-enrolled provider.

Medicaid Reform

In July of 2006 the Florida Medicaid program began Medicaid Reform in Broward and Duval Counties. In July 2007 Medicaid Reform expanded to Baker, Clay, and Nassau counties and, with legislative approval, will expand statewide by 2010.

The focus of reform is to give individuals choice in their health care. Under this reform program, Medicaid beneficiaries will choose among the Medicaid health plans available in their county, with the plans providing a coordinated system of care.

Under this reform program, Medicaid beneficiaries will choose among the Medicaid health plans available in their county, with the plans providing a coordinated system of care.

The services may vary from plan to plan as benefit packages are customized to meet the needs of specific groups. All mandatory services offered under the Medicaid program are still provided as well as some new services not available before.

New options available under Medicaid Reform include:

Individuals who participate in state-defined healthy activities may receive enhanced benefit credits which can be used for non-covered health services.
Beneficiaries with access to private insurance will be offered the choice to totally “opt-out” of Medicaid, with Medicaid paying a certain portion towards the purchase of an employer-sponsored health insurance plan or individual health plan for a self-insured individual.

During the initial phase of Medicaid Reform the following individuals may voluntarily enroll but are not required to do so: foster care children / adoption subsidies, individuals diagnosed with developmental disabilities, pregnant women in the SOBRA program, and individuals with Medicare coverage (dually eligible).

In addition, the following individuals are exempt from enrollment in Medicaid Reform: individuals eligible as Medically Needy, aliens receiving emergency assistance, women diagnosed with breast and cervical cancer, individuals in an institution, and those enrolled in the Family Planning Waiver.

Consumer information on Medicaid Reform and health plan choices available in the counties covered by Medicaid Reform can be found at www.FLMedicaidReform.com.

Additional information on Medicaid Reform can be viewed at http://ahca.MyFlorida.com (click “Medicaid” then click “Medicaid Reform”) or by contacting your local Medicaid office (See “AHCA’s Medicaid Offices” in this brochure).

Responsibilities of Government Agencies:

In Florida, the Agency for Health Care Administration (AHCA) operates the Medicaid program while the Department of Children and Families (DCF) determines who is eligible to receive Medicaid services.

In addition, the Social Security Administration determines eligibility for Supplemental Security Income (SSI is a federal program for aged, blind, and disabled persons with little or no income). For Florida residents, SSI participants are automatically eligible for Medicaid.

For further information on eligibility for these programs, contact the Department of Children and Families or the Social Security Administration (See the “Resource Directory” in this brochure).

The Agency for Health Care Administration (AHCA) has Area Offices throughout the state to serve Medicaid beneficiaries and providers. These Area Offices:

Provide consumer education and assistance
Provide a list of primary care physicians, dentists, and specialists who serve Medicaid beneficiaries
Answer questions about Medicaid services
Help Medicaid beneficiaries with MediPass and other Medicaid health plans
Manage the Child Health Check-Up program and authorize emergency (out-of-state) transportation services, and
For Medicaid health care providers, the Area Offices conduct credentialing site visits and assist with provider enrollment/re-enrollment. Provider relations staff also responds to telephone and e-mail inquiries regarding billing and policy issues, resolve exceptional claims, and offer routine provider training on a variety of topics.

To find the Area Office in your part of the state, see the section in this brochure, “AHCA’s Medicaid Offices.”

Additional government agencies that provide Medicaid related services include the Florida Department of Elder Affairs (CARES and Medicaid waiver programs for the elderly), County Health Departments (some direct medical care), and the Florida KidCare Program (insurance coverage for children). See the “Resource Directory” in this brochure for contact information.

Medical Services Covered by Florida Medicaid

Florida Medicaid covers a variety of medical services. The type and amount of services depends on the age of the beneficiary, the type of Medicaid program in which the beneficiary is enrolled, and the type of services determined medically necessary by the beneficiary’s Primary Care Provider.

Medicaid services may include: physician, hospital, family planning (birth control, pregnancy and birth care), home health care, nursing home, hospice, transportation, dental and visual, community behavioral health, services through the Child Health Check-Up program, and other types of services.

The Florida Medicaid program pays the cost of prescription drugs for those who qualify for this coverage. However, if you are covered by both Medicaid and Medicare, most of your prescription drugs may be provided under the Medicare Part D Prescription Drug benefit. There are a few drugs not covered by Medicare Part D plans, but these may be covered by Medicaid for persons with full Medicaid coverage.

Medicare Part D is an insurance benefit to help people with Medicare pay for prescription drugs and is provided through Medicare approved private health plans. You can find out more information by contacting Medicare (See the “Resource Directory” in this brochure). Ask about the Medicare Part D plans for Florida Medicaid beneficiaries.

For more detailed information about services covered by Florida Medicaid and the programs providing these services, refer to the publication, Florida Medicaid: Summary of Services. This publication can be viewed at http://ahca.MyFlorida.com (click Medicaid).

You can also call your AHCA Medicaid Area Office for information and questions about Medicaid services. See “AHCA’s Medicaid Offices” in this brochure for the office that serves your area of the state.

Medicaid Health Plans

Medicaid health plans coordinate care, to assure people receive the care they need in the best possible setting, while reducing unnecessary care. This ensures the quality of care provided and helps control costs. A state-sponsored program, Medicaid Options, assists Medicaid beneficiaries in non-reform counties enroll in one of the following health plans:

Medicaid health maintenance organizations (HMOs)
Medicaid Provider Access System (MediPass)
Provider Service Networks (PSNs)
Minority Physician Networks
Emergency Room Diversion projects, and
Children’s Medical Services (CMS) network for children with special health care needs

For help in choosing a Medicaid health plan and a primary care doctor, Medicaid beneficiaries in non-reform counties may call the Medicaid Option’s toll-free number (888) 367-6554 (or TDD 800-653-9803) or view the website www.MedicaidOptions.net.

Medicaid recipients who live in Baker, Broward, Clay, Duval, or Nassau counties (Medicaid Reform counties), may call the Medicaid Choice Counseling Helpline toll-free number (866) 454-3959 (or TDD 866-467-4970).

Medicaid vs. Medicare

Medicaid and Medicare are two separate programs. Medicaid is a program for people with low income who meet certain eligibility requirements and programs can vary from state-to-state. Medicare is a federal health insurance program for people who are age 65 or older, disabled persons, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

If you have questions about Medicare, call the toll-free number (800) 633-4227 (or TTY 877-486-2048) or view the website www.Medicare.gov.

Medicaid and Medicare Can Work Together:

If you are covered by both Medicare and Medicaid, the Florida Medicaid program may cover:

Your Medicare deductible (portion you pay before Medicare starts to pay for covered services)
A portion of your Medicare co-payment and co-insurance (portion of cost you share with Medicare for some covered services)
Premiums you pay for Medicare coverage
Some services or items Medicare does not cover (up to the amount Medicaid will cover)

If you receive Medicare only, you may still be eligible to get help from Florida Medicaid to cover the above expenses. These benefits are offered through the following programs: Qualified Medicare Beneficiaries (QMB), Qualifying Individuals 1 (formerly Part B Medicare Only), and Special Low-Income Medicare Beneficiaries (SLMB). To apply for one of these programs or to receive additional information, contact the Department of Children and Families (See the “Resource Directory” in this brochure).

Frequently Asked Questions

Who is eligible for Florida Medicaid?

The following people may qualify for Florida Medicaid if they meet certain financial requirements:

Low-income families with children
Pregnant women
Infants and children under the age of 21
Recipients of Supplemental Security Income (SSI)
People who are aged 65 or older
People who are blind or expected to be disabled for at least a year
People who need nursing home care or home and community-based care
People who are on Medicare
Aliens and refugees under a special assistance program (Emergency Medicaid)
Individuals who are medically needy

Who are Medically Needy beneficiaries?

People who have large monthly medical bills may be able to get Medicaid assistance even if their income and resources exceed the requirements for Florida Medicaid eligibility. Their Medicaid eligibility is evaluated every month.

These Medicaid beneficiaries may have to pay a portion of their monthly medical costs before Florida Medicaid will cover the rest of their medical bills. This is called “share of cost.” The amount of the share depends on the patient’s monthly income and medical expenses.

Do I have to live in Florida a certain amount of time before I can apply?

It is not necessary to have lived in Florida for a certain length of time, but you need to be a resident of Florida. If you just moved to Florida and were covered by Medicaid in another state, you will still need to apply for Medicaid in Florida. However, if you are a recipient of Supplemental Security Income (SSI) you can simply contact the Social Security Office to report your new address.

How do I apply for Medicaid?

Applications for Medicaid are made through the Florida Department of Children and Families (DCF). Applications are available on-line at www.MyFlorida.com/cf_web or by calling the DCF toll-free number (866) 762-2237.

If you do not have a computer at home, check your local library, school, or community center for possible computer use and Internet access. Also, local service centers of the Department of Children and Families provide computers for filing an application.

What documents will I need when I apply for Medicaid?

When you apply for Medicaid, you must fill out an application form. You will also need to have various documents:

Information about household members (name, date of birth and Social Security number)
Rent or mortgage information
Expenses (utilities, daycare, etc.)
Vehicle information
Bank statements
Income (pay stubs)
Proof of disability or medical records showing a lasting medical condition
Recent medical bills
Proof of citizenship
Additional information as requested

Can I get Medicaid if I have a car, a house, and some savings?

Having a car, house, and some savings, within certain limits, does not prevent you from getting Medicaid.

How long will it take to decide my Medicaid eligibility?

After you complete your application, the Department of Children and Families must decide within 45 days if you are eligible to receive Medicaid. If you are disabled, the limit for eligibility determination is 90 days. If you disagree with the decision, you may ask for a hearing.

When does my Medicaid coverage begin and end?

Generally, if you request retroactive coverage during your application process and meet all Medicaid requirements, your bills for the three months before the date of your application may be covered. Coverage usually ends at the end of the month you no longer meet Medicaid eligibility requirements.

For individuals in the Medically Needy Program, coverage begins on the day the individual meets his or her share of cost, and continues through the end of that month. Eligibility for coverage under the Medically Needy Program is redetermined for each month a beneficiary presents an unpaid medical bill.

How do I find a Medicaid health care provider?

If you are covered by regular Medicaid contact your local Medicaid office for a list of primary care doctors, dentists, and specialists (See “AHCA’s Medicaid Offices” in this brochure).

If you are in a Medicaid health plan contact the plan for a list of Medicaid providers. Call the health plan customer service number listed on your medical card or other paperwork the health plan gave you.

To see a medical specialist, a dentist, or to receive certain services you may be required to ask your primary care doctor for a referral.
To make an appointment with a Medicaid provider you need to contact the doctor’s office and ask if they are accepting new Medicaid patients. Doctors, medical specialists, and dentists who serve Medicaid patients might serve only a certain number of patients at a time.

What are co-payments and co-insurance?

Co-payments and co-insurance are amounts of money you pay directly to the provider for the service you receive. Medicaid beneficiaries are required to pay a co-payment and co-insurance for certain services, unless they are exempted. Contact your local Medicaid office for further information (See “AHCA’s Medicaid Offices” in this brochure).

Where can I report possible Medicaid fraud or abuse?

If you suspect Medicaid fraud or abuse, please call the toll-free number (800) 419-3456.

What if I do not qualify for Medicaid but I need medical help?

Try calling the phone number 2-1-1. This is a community referral service which lists the various programs in a community that serve people in need. This number is slowly being introduced throughout Florida.

Check the website www.FloridaHealthFinder.gov (click Medical Help Resources) for a list of groups and programs that provide information, referral, or help with the cost of medical care and other expenses.

Check the website http://ask.hrsa.gov/pc to find a clinic in your community that provides health care services, even if you don’t have insurance or money.

Contact your local county health department for direct medical care and information on other programs that may be available in your community (See the “Resource Directory” in this brochure).

If you have uninsured children under the age of 19, you may be able to get them health insurance coverage through the Florida KidCare Program (See the “Resource Directory” in this brochure).

If you are a senior, call the Florida Department of Elder Affairs toll-free helpline at (800) 963-5337 (or TDD 800-955-8771) to ask about their programs and for referral to other programs that might be able to help.

AHCA’s Medicaid Offices

Look for your county in the following list, to find the office which serves your area of the state. You may contact the office for information on Medicaid services, a list of Medicaid providers, Medicaid health plans, consumer education, and information for Medicaid providers. To apply for Medicaid see the Department of Children and Families in the “Resource Directory” of this brochure.

Area 1
Escambia, Okaloosa, Santa Rosa, and Walton
(850) 595-5700
(800) 303-2422 (toll free)

Area 2a
Bay: (850) 872-7690
Franklin, Gulf, Holmes, Jackson and Washington
(800) 226-7690 (toll free)

Area 2b
Calhoun, Gadsden, Jefferson, Leon, Madison y Wakulla:
(850) 487-2272
Liberty and Taylor:
(800) 248-2243 (toll free)

Area 3a
Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, and Union
(386) 418-5350
(800) 803-3245 (toll free)

Area 3b
Citrus, Hernando, Lake, Marion, and Sumter
(352) 732-1349
(877) 724-2358 (toll-free)

Area 4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
(904) 353-2100
(800) 273-5880 (toll free)

Area 5
Pasco and Pinellas
(727) 552-1191
(800) 299-4844 (toll free)

Area 6
Hardee, Highlands, Hillsborough, Manatee, and Polk
(813) 871-7600
(800) 226-2316 (toll free)

Area 7
Brevard, Orange, Osceola, and Seminole
(407) 317-7851
(877) 254-1055 (toll free)

Area 8
Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
(239) 338-2620
(800) 226-6735 (toll free)

Area 9
Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
(561) 616-5255
(800) 226-5082 (toll free)

Area 10
Broward
(954) 202-3200
(866) 875-9131 (toll free)

Area 11
Miami-Dade and Monroe
(305) 499-2000
(800) 953-0555 (toll free)

Resource Directory

Florida Agency for Health Care Administration
http://ahca.MyFlorida.com, www.FloridaHealthFinder.gov, www.MyFloridaRx.com
(888) 419-3456

Florida Department of Children and Families
www.MyFlorida.com/cf_web
(866) 762-2237

Florida Department of Elder Affairs
http://ElderAffairs.state.fl.us
(800) 963-5337
(800) 955-8771 (TDD)

Florida Department of Health
County Health Departments
www.FloridasHealth.com

Florida KidCare
www.FloridaKidCare.org
(888) 540-5437
(877) 316-8748 (TTY)

Medicare
www.Medicare.gov
(800) 633-4227
(877) 486-2048 (TTY)

Social Security Administration
www.ssa.gov
(800) 772-1213
(800) 325-0778 (TTY)

Additional consumer brochures include:

A Consumer’s Guide to Health and Human Services Programs
A Patient’s Guide to a Hospital Stay
Assisted Living in Florida
Emergency Medical Care
End-of-Life Issues – A Practical Planning Guide
Health Care Advance Directives
Home Health Care in Florida
Long-Term Care
Patient Safety
Understanding Prescription Drug Costs

For additional copies of this brochure, or others in the series, please contact the AHCA Call Center’s toll-free number (888) 419-3456. To view or print any brochure in the Consumer Awareness Series please visit www.FloridaHealthFinder.gov .

This brochure may be copied for public use. Please credit the Agency for Health Care Administration for its creation.

If you have comments or suggestions, please call (850) 922-5771.

The Agency for Health Care Administration established the following websites to help Florida residents be well informed health care consumers.

www.FloridaHealthFinder.gov provides search tools to compare short-term acute care hospitals, ambulatory (outpatient) surgery centers, health plans, and nursing homes. The site includes the A.D.A.M. Health Encyclopedia with thousands of articles and illustrations. The site also provides a list of health care facilities; information about insurance, medications, seniors, medical conditions, and resources for medical care; a variety of consumer publications; information for health care professionals; and much more.

www.MyFloridaRx.com
This website provides pricing information for the top most commonly used prescription drugs in Florida.

http://ahca.MyFlorida.com
This website includes information on health care facility regulation and licensing, the Florida Medicaid program, managed care (HMOs), and other topics related to the Agency for Health Care Administration.