Ending the COVID-19 Related Continuous Medicaid Coverage Requirement: Considerations for Medically Needy Medicaid Recipients

Background:  In the face of the  COVID-19 pandemic, 2020 legislation provided states with significant federal funding to ensure continuous Medicaid coverage of individuals enrolled in the program, even those who are no longer technically eligible. States were required to maintain this moratorium on terminations until the end of the Public Health Emergency (also referred to as the PHE). In late December 2022, the law was changed to “de-link” the requirement of continuous Medicaid from the end of the PHE. Although the PHE is still in effect, the continuous Medicaid coverage requirement ends March 31, 2023.

Under Florida’s plan, the Department of Children and Families (DCF) will begin reviewing the eligibility of approximately 4.9 million Floridians currently on the Medicaid program beginning in March 2023, and the reviews will be completed by April 2024.

Description of the Medically Needy Program and the “Share of Cost” Requirement: The Medically Needy program is available to those who fit into one of Florida’s Medicaid coverage categories:  (1) children age 20 and younger, (2) parents/caregivers of minor child(ren), (3) pregnant women including one year postpartum, (4) people with disabilities, and (5) people age 65 or over.  If a person in one of these categories applies for Medicaid but has too much money to qualify,  they will be enrolled in the “Medically Needy” program. When enrolled, DCF assigns the person a “share of cost,” which is like a deductible. If an individual incurs medical expenses (paid or unpaid) that meet or exceed their share of cost, the individual is eligible for Medicaid from the day that they meet their share of cost until the end of the month. For more information on the Medically Needy program, click here and here.

For example, Seth is a teenager diagnosed with cerebral palsy who lives at home with his two parents. Seth’s parents collectively earn a gross income of $72,000 per year (or $6,000 per month) and have since March 2020. The 2022 Medicaid eligibility income limit for children age 18 and younger living in a household of 3 people is no more than $2649. In March 2020, Seth was 16 years old and enrolled in the Medically Needy program. DCF assigned him a share of cost in the amount of $5,514 per month. Seth met his share of cost in April 2020 based on the cost of a hospitalization. When Seth met his share of cost in April 2020, he became  Medicaid eligible.  And, because of the continuous enrollment requirement, his Medicaid coverage has continued without having to meet his share of cost each month.

What will happen when DCF returns to its normal enrollment and eligibility procedures after March 31, 2023? DCF will do what is called an “ex parte” review for everyone on Medicaid. This means DCF will look at the person’s information on file and determine whether the person remains eligible for their current coverage category, or another category, or if more information is needed. A notice will be sent to the person after that review.   Under DCF’s plan for prioritizing  redeterminations, vulnerable groups such as children under age 21 diagnosed with a medically complex condition will be redetermined at the end of the 12 month period.

For people who have been receiving ongoing Medicaid because they have met a share of cost one or more months since March 2020, they will now only receive Medicaid coverage from the day they meet their share of cost until the end of that same month.

What will happen to Seth?  When Seth’s case comes up for renewal after the continuous coverage requirement ends, DCF will redetermine Seth’s eligibility for the medically needy program. Because Seth’s parents’ income has not changed since March 2020, DCF will redetermine him as eligible for the Medically Needy program and he will maintain the same share of cost. However, he will be required to establish that he meets his share of cost every month in order to get Medicaid for that month.

What options do those in the Medically Needy program have after the continuous coverage requirement ends? If you believe that DCF did not make the correct decision about your eligibility or share of cost, you can appeal. The instructions for appealing can be found in your notice.

What can those receiving Medicaid under the Medically Needy Program do to prepare?

• Update your ACCESS account information to ensure DCF has the most recent information about your household income and status, as well as your updated address.

• If you are disabled: apply for benefits, including Supplemental Security Income (SSI), with the Social Security Administration as soon as possible. Here is information on how to apply. This is particularly important for children who were receiving their Medicaid coverage through the Medically Needy program but have since turned age 18. At age 18, the income of a person’s parents is no longer counted in determining  eligibility for SSI.

Seth should apply for SSI because he turned  18 during the pandemic and his parents income will no longer be used to determine his eligibility. He should also consider applying for Medicaid as a household of one(1) when he turns 19. This Q & A has important information..

If your child is over income for Medicaid and under age 19, you can also apply for KidCare. KidCare requires payment of a premium which is income dependent. If you’re over income for the subsidized KidCare program, you can pay a larger premium for the full-pay program. KidCare benefits are very similar to Medicaid benefits and include coverage like durable medical equipment and private duty nursing.