Most Medicaid planning lawyers are spending the vast majority of their time representing clients interested in obtaining or preserving Institutional Care Program Medicaid (for those needing skilled nursing facility level of care) and Home and Community Based Service Medicaid (for those who need extra help at home or in an ALF). However, some Medicaid planning clients are looking to obtain or preserve their benefits from some lesser-known Medicaid programs focused on supporting Florida’s elderly community. Typically, these clients come to me after being notified that they are about to receive an inheritance or personal injury settlement and do not want to lose their Medicaid.

The first two Medicaid programs fall under the “Community Medicaid” heading and consist of: Medically Needy and MEDS-AD (Medicaid for Aged and Disabled)

Medically Needy Medicaid

The Medically Needy Medicaid program, also referred to as “share of cost” Medicaid,  is for people who are elderly (65+) or disabled. Read DCF’s brochure on the Medically Needy Program here. Eligibility for the Medically Needy requires that applicants have $5,000 (or less) in countable assets for an individual ($6,000 for a couple). There is no specific income threshold (take monthly income and subtract $180.00), but the idea is that one’s income is too high to qualify for other Medicaid programs, but too low to afford “allowable expenses,” which include Medicare + other health insurance premiums, co-insurance payments, medical goods and services prescribed by a doctor, hospitalizations, prescription medicines and medical transportation providers to obtain medical care - as long as all services are provided by enrolled Medicaid providers. For questions on what expenses count call DCF at 1-866-762-2237.

Medically Needy recipients cannot use over the counter medicines or supplies (e.g. aspirin or ace bandages) or non-health insurance premiums toward their share of cost.

What is the Share of Cost part of the Medically Needy Program?

The Florida Medicaid "Medically Needy" program is referred to as a “share of cost” because the Medicaid beneficiary must pay a portion of their income each month before Medicaid is approved. You can think of the share of cost as a deductible based on your family’s monthly income and how much it exceeds traditional Medicaid income limits. So you start each month without Medicaid health insurance coverage. Only when your allowable expenses equal your share of cost in any calendar month, will you be eligible for Medicaid for the rest of that same calendar month.

For example, if your share of cost is calculated at $675.00 and you go to the ER and receive a bill for $1,150, you would fax, mail or walk that (and other) bill into an ACCESS Florida office to prove that you have met your share of cost and Medicaid will pay the bill and any other allowable expenses for the rest of that month.

If your share of costs is $675.00 and you go to the doctor and only receive a bill for $150.00, you have not met your “share of cost” and you will have to pay that bill in full. However, if later the same month you go to the hospital and receive a bill for $550.00, you would submit both bills to Medicaid (through ACCESS Florida) and the bill for $550.00 (and any allowable expenses incurred afterwards) would be covered by Medicaid.

On the first of the next calendar month you start the Medically Needy share of cost calculation all over again.

MEDS-AD - MEDS for the Aged and Disabled

For those who qualify, typically for those who do not have Medicare A or B, MEDS-AD will pay bills from doctors, hospitals, drug/prescription costs, PT, OT and short term rehab stays.

MEDS-AD Medicaid Income and Asset Thresholds

As of July 2017 (all asset and income test numbers are subject to periodic change), individuals can earn no more than $885.00 in monthly income (couples together can earn no more than $1,191.00/mo). Individuals must have no more than $5,000.00 in combined countable assets (couples = $6,000.00 in countable assets)

PACE - Program of All-Inclusive Care for the Elderly

PACE is a Medicare and Medicaid partnership. PACE eligibility requirements include being 55+ and disabled or 65 years or older. PACE must be the Medicare and Medicaid provider. PACE programs are organized around the local PACE Center and are designed to keep participants in the home or community as opposed to an institution. Financial Eligibility is similar to ICP / Long Term Care Medicaid Eligibility Requirements in Florida with no income restrictions for the well spouse only (asset test, income test, CSRA otherwise identical).  

What does PACE provide? PACE centers provide: adult day care, doctor’s offices, nursing services, social services, rehabilitation services, meals, recreational therapy, nutritional counseling, PT, OT, and more.

PACE is not currently available throughout Florida. Currently, PACE is available in Miami-Dade, Palm Beach, Lee, Collier and Charlotte counties. Click here to find a Florida PACE program near you.

Although I represent Medicaid clients throughout the state - the bulk of my elder law practice is in South Florida. The following PACE locations will be most applicable to the majority of my clients:

  • In Miami - the PACE Center is at Miami Jewish Health Systems on 5200 NE 2nd Avenue, Miami, FL 33137 | 305.751.7223.
  • There are no PACE locations in Broward County.
  • In Palm beach, the PACE Center is at Morse Life on 4847 Fred Gladstone Drive, West Palm Beach, FL 33417 | 561.868.2999.

PACE also pays for hospitalizations, regular doctors visits, prescriptions, elder supplies such as diapers and wheelchairs, caregiver support, ALF, skilled rehab and nursing home care. PACE provides transportation to and from PACE facilities where they have activities for PACE members.

Florida Medicare Savings Programs

In Florida there are several Medicaid benefits that fall under the category of “Medicare Savings Programs” - design to, as you may have guessed, to pay for Medicare premiums, deductibles, coinsurance and copayments for those who qualify. The Medicare Savings Programs addressed in this article include: Qualified Medicare Beneficiary (QMB); Special Low-Income Medicare Beneficiary (SLMB) and Qualifying Individuals (QI-1). More info about Medicare Savings Programs here.

The QMB, SLMB and QI-1 Asset Limits (as of July 2017) are as follows:

Individual: $7,390.00

Couple: $11,090.00

QMB - Qualified Medicare Beneficiary

QMB Medicaid helps people pay Medicare Part A premiums, Medicare Part B premiums and accompanying deductibles and copays. To qualify one must already be enrolled in Medicare Part A (when to enroll in Medicare is further discussed here). QMB asset limits are discussed above.

QMB Income Limits (as of July 2017)

Individual: $1,005.00/month

Couple: $1,354.00/month

SLMB - Special Low-Income Medicare Beneficiary

SLMB Medicaid helps those who qualify pay for Medicare Part B premiums only. SLMB asset limits are discussed above.

SLMB Income Limits (as of July 2017)

Individual: $1,206.00  |  Couple: $1,624.00

QI-1 (Qualifying Individuals 1)

This Medicare Savings Plan may involve a waiting list and must be reapplied for every year (although those who were qualified in a prior year get preference).  QI1 Asset Test limits are discussed above.

QI1 Income Limits (as of July 2017)

Individual: $1,357.00  |  Couple: $1,827.00

Other Medicaid Resources

Important Florida Medicaid Numbers

ESS - Financial Eligibility Standards

Different Medicaid Programs Available in Florida