(1) Date of Eligibility. Eligibility for Medicaid begins the first day of a month if an individual was eligible any time during the month, except as provided below:
    (a) Presumptive Eligibility for Pregnant Women (PEPW). The period of presumptive eligibility for pregnant women begins when a Qualified Designated provider, as defined in Fl. Admin. Code R. 65A-1.701, determines that the woman is eligible. Presumptive eligibility ends when a determination for full Medicaid is made (approved or denied), or on the last day of the month following the month the presumptive eligibility determination is made if an application for ongoing Medicaid coverage is not filed.
    (b) Presumptive Eligibility by Hospitals. The period of presumptive eligibility by hospitals begins on the date the determination is made. Presumptive eligibility ends when a determination for full Medicaid is made (approved or denied) or on the last day of the month following the month the presumptive eligibility determination is made if an application for ongoing Medicaid coverage is not filed.
    (c) Presumptive Eligiblity for Newborn (PEN). Eligibilty for a presumptively eligible newborn begins on the date of birth and continues for one year unless one of the following occurs:
    1. The child leaves the state,
    2. The child dies, or
    3. There is a request for voluntary closure.
    (d) Medically Needy Program. Enrollment under the Medically Needy Program begins on the first day of the month the individual satisfies the non-financial and resource eligibility criteria, if applicable, but not earlier than the third month prior to the month of application. Medicaid Eligibilty under the Medically Needy Program begins on the date their incurred allowable medical expenses equal the amount of their share of cost (SOC).
    (e) Emergency Medicaid for Aliens (EMA). Coverage for individuals eligible for EMA begins the first day of a covered emergency and ends the day following the last day of the emergency medical situation. A Medicaid renewal date of 12 months will be assigned. Subsequent medical emergencies require documentation, but the individual will not have to file a new application and the Department will not make a new eligibility determination during this 12 month period. Changes in the SFU circumstances will continue to affect eligibility.
    (2) Processing Medicaid Applications for Supplemental Security Income (SSI) Denials.
    (a) The Department will use data obtained from the Social Security Administration’s (SSA) State Data Exchange (SDX) to identify individuals who have been denied SSI benefits.
    (b) The Department will identify the individuals for whom the Department does not have an open Medicaid case or a pending Medicaid application at the time the SDX data is received. The Department will explore eligibilty under another coverage group with information based on available information receieved from the SDX data. If additional information is required to make a determination, these individuals or their SSA payee will be notified in writing to contact the Department within 30 calendar days. Failure to do so without good cause, will result in the issuance of a written notice of Medicaid denial for failure to follow through in determining eligibility.
    (c) Good cause means illness of the individual or a family member, an accident involving the individual or a family member, hospitalization of the individual or a family member, death of the individual or a family member, natural disasters in a relevant geographical area, being away from home or the unexpected closure of a Department’s office.
    (d) Those individuals whom the Department identifies as having an open Medicaid case or a pending Medicaid application at the time the SDX data is reviewed will not be required to contact the Department, unless additional information is needed to complete the eligibility process.
    (e) A determination of eligibility will be completed on the individuals who respond to written notice to contact the Department.
    (3) Ex Parte Process.
    (a) When a recipient’s eligibility for Medicaid ends under one coverage group, the Department must evaluate their eligibility, using available information, under any other Medicaid coverage group before terminating Medicaid coverage. If additional information is required to make an ex parte determination it can be requested from the recipient. There is no requirement for the individual to contact the Department or file an application to initiate the ex parte review for continued Medicaid eligibility.
    (b) All individuals who lose Medicaid eligibility under one coverage group will continue to receive Medicaid under that coverage group until the ex parte Medicaid renewal process is complete.
    (c) Qualified individuals losing eligibility due to income that was calculated based on the Modified Adjusted Gross Income (MAGI) budgeting methodology will be transferred to the Children’s Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM) for a determination of eligibility.
    (4) Requirement to File for Other Benefits. As a condition of eligibility for Medicaid, the Department must require an individual to take all necessary steps to obtain any annuities, pensions, retirement, and disabilty benefits to which they are entitled, unless they can show good cause, as defined in paragraph (2)(c) of this rule, for not doing so. Annuities, pensions, retirement and disability benefits include, but are not limited to, veterans’ compensation and pensions, OASDI benefits, railroad retirement benefits, and unemployment compensation. After the Department notifies an individual that they must apply for the other benefit(s), if the individual fails to do so, they are not eligible for Medicaid.
    (5) Child Support Enforcement Cooperation (CSE). For the purpose of establishing Medicaid eligibility, a pregnant woman is not required to cooperate with CSE as a condition of eligibility. Cooperation with CSE is also not required in Medicaid cases where benefits are only requested for a child.
    (6) Re-evaluating Medicaid Adverse Actions for Individuals who do not Request a Hearing. The Department shall re-evaluate any adverse Medicaid determination upon a showing of good cause by the individual that the Department’s previous determination was incorrect. This provision applies only when benefits were terminated or denied in error or the amount of a share of cost or patient responsibility was determined incorrectly. A re-evaluation must be requested within 12 months from the effective date of the notice of adverse action.
    (a) Good cause for establishing the previous determination was incorrect consists of any of the following:
    1. Mathematical Error – The Department made a mechanical, computer or human error in its mathematical computations of resources or income requirements for Medicaid eligibility.
    2. Records Error – The Department made an error in a Medicaid determination which caused an incorrect decision. For example, there is evidence showing that the individual’s resources satisfied Florida’s standard of eligibility but the application was denied on the basis of excess resources.
    3. New and Material Evidence – The Department’s determination was correct when made but new and material evidence that the Department did not previously consider establishes that a different decision should be made.
    (b) Good cause for not requesting a hearing within the prescribed 90 day time period exists when the failure was due to circumstances beyond the individual’s control or due to an unexpected closure of Department offices.
    (c) Failure of the individual to provide information required by the Department to accurately determine eligibility for Medicaid where the failure was beyond the individual’s control constitutes good cause for re-evaluation. However, if the individual fails to cooperate with the Department in establishing eligibility, good cause for re-evaluation does not exist.
    (d) The Economic Self Sufficiency Specialist (ESSS) is responsible for the initial determination of whether good cause for re-evaluation exists. The decision must be reviewed by the ESSS’s supervisor. If both the ESSS and the ESSS’s supervisor determine that good cause does not exist, the next level administrator, in consultation with the Regional Program Administrator, must review the decision.
    1. If a determination is made by the Regional Program Administrator that good cause does not exist, the individual will be notified of the decision and of the right to to request a fair hearing.
    2. If a determination is made by the Regional Program Administrator that good cause exists and the Department discovers that an error was made in the eligibility determination, benefits must be provided retroactively as follows:
    a. If an application was denied, benefits will be awarded back to the date of application, provided all other eligibility requirements are met.
    b. If an ongoing case was terminated, benefits will be awarded back to the effective date of the termination, provided all other eligibility requirements are met.
    3. If a determination is made by the Regional Program Administrator that good cause exists and the original determination is determined to be correct, the individual will be notified of the Department’s decision. The individual has 90 calendar days from the date of notice of disposition to request a hearing. If at the end of 90 calendar days a hearing is not requested, the Department’s decision is final and binding upon the individual.
    (7) Assignment of Rights to Benefits. Each individual applying for or receiving Medicaid must cooperate in securing the receipt of medical support and payments from third parties that are otherwise due to the individual, unless good cause exists for not cooperating. Good cause exists when the individual previously applied for and was denied third party benefits or medical support, and the reason for denial has not changed.
    (8) Retroactive Medicaid. Retroactive Medicaid is based on an approved, denied, or pending application for ongoing Medicaid benefits. For applications submitted on or after February 1, 2019, retroactive coverage only applies to applications for children under age 21 and pregnant women, including their postpartum period.
    (a) Retroactive Medicaid eligibility is not effective before the third month prior to the month of application. The individual must meet all Medicaid eligibility requirements during the retroactive months. A request for retroactive Medicaid can be made for a deceased individual by a designated representative or caretaker relative, by filing a medical assistance application. However, Qualified Medicare Beneficiaries (QMB’s) are not eligible for retroactive Medicaid benefits as indicated in Title XIX of the Social-Security Act §1902(e)(8).
    (b) SSI Cash Assistance Recipients. Upon SSI approval, all SSI recipients receive a system-generated notice of potential entitlement for retroactive Medicaid benefits and a reply card to be returned to the Department if the SSI recipient is interested in receiving retroactive Medicaid benefits. If the SSI recipient or their designated representative or caretaker relative contacts the Department, the Department will proceed with an eligibility determination.
    (9) Re-Enrollment. In order for an individual or family to be eligible for re-enrollment in the Medically Needy program, they must:
    (a) Continue to satisfy the resource criteria, if applicable;
    (b) Continue to satisfy all non-financial eligibility criteria; and
    (c) Provide verifications as needed. The re-enrollment period may exceed 12 months when there is a delay in the Department’s processing of the re-enrollment.
    (10) Limits of Coverage.
    (a) Qualified Medicare Beneficiary (QMB). Under QMB coverage, individuals are eligible for Medicare cost-sharing benefits, including payment of Medicare premiums.
    (b) Specified Low-Income Medicare Beneficiary (SLMB). Under SLMB coverage, individuals are eligible for payment of the Part B Medicare premium. If eligible, AHCA will pay the premium for up to three months retroactive to the month of application.
    (c) Working Disabled (WD). Under WD coverage, individuals are eligible for payment of their Medicare Part A premium.
    (d) Qualifying Individuals 1 (QI1). Under QI1 coverage, individuals are eligible for payment of their Medicare Part B premium. (This is coverage for individuals who would be eligible for QMB or SLMB coverage except that their income exceeds the limits for those programs.) If eligible, AHCA will pay the premium for up to three months retroactive to the month of application.
    (11) Determining Share of Cost (SOC). The SOC is determined by deducting the appropriate Medically Needy Income Level from the individual’s or family’s income.
    (12) Eligibility of SSI Cash Assistance Recipients. Eligible SSI recipients who are residents of Florida are automatically eligible for Medicaid pursuant to 42 C.F.R. § 435.120.
    (13) Trusts.
    (a) The Department applies trust provisions set forth in §1902 of the Social Security Act.
    (b) Funds transferred into a trust or other similar device established other than by a will prior to October 1, 1993, by the individual, a spouse, or a legal representative are available resources if the trust is revocable or if the trustee has any discretion over the distribution of the principal. Such funds are a transfer of a resource or income, if the trust is irrevocable and the trustee does not have discretion over distribution of the corpus, or if the individual is not the beneficiary. No penalty can be imposed when the transfer occurs beyond the 60 month look-back period. Any disbursements which can be made from the trust to the individual or to someone else on the individual’s behalf shall be considered available income to the individual. Any language which limits the authority of a trustee to distribute funds from a trust, if such distribution would disqualify an individual from participation in government programs, including Medicaid, shall be disregarded.
    (c) Funds transferred into a trust, other than a trust specified in 42 U.S.C. § 1396p(d)(4), by a person or entity specified in 42 U.S.C. § 1396p(d)(2) on or after October 1, 1993, shall be considered available resources or income to the individual in accordance with 42 U.S.C. § 1396p(d)(3) if there are any circumstances under which disbursement of funds from the trust could be made to the individual or to someone else for the benefit of the individual. If no disbursement can be made to the individual or to someone else on behalf of the individual, the establishment of the trust shall be considered a transfer of resources or income.
    (d) The trustee of a qualified income trust, qualified disabled trust, or a pooled trust shall provide quarterly statements to the Department which identify all deposits to and disbursements from the trust for each month during the eligibility period.
    (e) Undue Hardship. A period of ineligibility shall not be imposed if the Department determines that the denial of eligibility based on counting funds in an irrevocable trust according to provisions in Fl. Admin. Code R. 65A-1.702(13)(b), would create an undue hardship on the individual. Undue hardship exists when application of a trust policy would deprive an individual of food, clothing, shelter or medical care such that their life or health would be endangered. This can be caused by legal restrictions or by illegal actions of a trustee. All efforts by the individual, or their legal spouse or representative, to access the resources or income must be exhausted before this exception applies.
    (14) Statewide Inpatient Psychiatric Program (SIPP). SIPP is for Medicaid eligible children under the age of 21 who require a residential level of care for treatment of a serious emotional disturbance. Those who are Medically Needy and those who are Medicare recipients are excluded from this program. Services must be received from a designated SIPP provider selected by the Agency for Health Care Administration (AHCA). SIPP providers must be licensed as a hospital or residential treatment center for children and adolescents by AHCA. This program provides an exception to provisions that residents of an institution for mental disease (IMD) are not eligible for Medicaid.
Rulemaking Authority 409.919 FS. Law Implemented 409.903, 409.904, 409.919 FS. History-New 10-8-97, Amended 4-22-98, 2-15-01, 9-24-01, 11-23-04, 5-31-06, 8-10-06, 3-25-20.