James Black is a native Floridian who has worked hard his entire life. James is a handyman, boatbuilder, and carpenter. His specialty is flooring. He is passing on his impressive skill to his 16 year old adopted son, and is proud to share that his son “can fix just about anything.”

Like many Floridians in their 50s and 60s who have spent decades lifting heavy building materials and on their knees, he can no longer do that work without first getting orthopedic care. For James that means a new knee.

In addition to his knee issue, James has nodules on his lungs that have not yet been diagnosed. He also needs a CT scan to make sure they are not malignant.

James lost his job with the early pandemic shutdown. When he did try to return to flooring work, his blood pressure sky-rocketed and he was hospitalized for 4 days.

After recovering from that episode, James tried another line of work; he started delivering for Amazon as a subcontractor, a job which requires using one’s own vehicle. His income, about $800/month, ended when his car was repossessed.

James desperately needs his knee fixed and his lung nodules examined. Like his wife, Melissa, he was enrolled in the Medically Needy program. But until Melissa reached out to FHJP, and we sorted through the family’s ACCESS account, James did not know he was and has been on full Medicaid as a Medically Needy enrollee with a “Patient Responsibility” of $0 since April 23, 2020.

Unfortunately, James was never sent a notice informing him that he was on Medicaid; and he was never sent a Medicaid card. The notices sent to the family were confusing; they showed their share of cost varying wildly from month to month. The last amount was $ 2,581—more than the family’s combined income. And none of the 18 notices between April 2020 and December 2022 explained that the Blacks were on full Medicaid and did not have to meet their monthly share of cost as long as the pandemic-related continuous coverage requirement remained in effect.

Beginning in March 2023 and over the next 12 months, approximately 1/12th of the state’s Medicaid enrollees will go through “redetermination” to see if they are still eligible for Medicaid. According to the family’s ACCESS account in April 2023, they are scheduled for their redetermination in October 2023. That gives James roughly 6 months in which he needs to schedule and receive critical health care.

When the family’s eligibility is redetermined, in October, here’s what will /should happen: their the 16 year old son will stay covered because Income limits for children are much higher than for adults, plus he is guaranteed Medicaid as part of his adoption assistance; Melissa and James will be no longer have “Patient Responsibility” of $0 for their share of cost; Melissa will have Medicare; QMB and Part D Extra Help. This confusing status for Melissa essentially amounts to full healthcare coverage—but only if her providers understand that they cannot balance bill someone on QMB. This is a problem requiring massive outreach and education of providers.

By contrast, James will likely end up with no healthcare coverage. Because his family’s income is more than $590 (the maximum amount a family of 3 can earn and be eligible for Medicaid) but less than $2,072/month (the minimum income required for subsidies in a marketplace (“Obamacare”) plan, he falls in the “coverage gap.” This gap exists in Florida and 9 other states that have refused to expand Medicaid. To recap: the 2010 Affordable Care Act provided 2 paths to affordable coverage: subsidies for those low-to-moderate income families earning between 100% and 400% of poverty (between about $ 2000 and $ 8300/month for a family of 3). Second, it required states to greatly expand their Medicaid programs to cover any low income uninsured adults. But in 2012 the Supreme Court ruled that Medicaid expansion would not be required; instead, each state could decide.

Thus, if Florida had expanded Medicaid, both Melissa and James would simply remain on Medicaid when their case is redetermined. Instead, Melissa will need to continually inform her providers that they cannot charge her copayments, and James will join the ranks of uninsured older Floridians.

“I don’t want to apply for disability. I want to work; I love to work. But I need to fix my knee and lungs.” James said, adding “If the notices were less confusing; and our leaders made Medicaid more available for working low-income adults, life would be a lot better for Florida families like ours.”

Beginning in March 2023 and over the next 12 months, approximately 1/12th of the state’s Medicaid enrollees will go through “redetermination” to see if they are still eligible for Medicaid. According to the family’s ACCESS account in April 2023, they are scheduled for their redetermination in October 2023. That gives James roughly 6 months in which he needs to schedule and receive critical health care.

When the family’s eligibility is redetermined, in October, here’s what will /should happen: their the 16 year old son will stay covered because Income limits for children are much higher than for adults, plus he is guaranteed Medicaid as part of his adoption assistance; Melissa and James will be no longer have “Patient Responsibility” of $0 for their share of cost; Melissa will have Medicare; QMB and Part D Extra Help. This confusing status for Melissa essentially amounts to full healthcare coverage—but only if her providers understand that they cannot balance bill someone on QMB. This is a problem requiring massive outreach and education of providers.

By contrast, James will likely end up with no healthcare coverage. Because his family’s income is more than $590 (the maximum amount a family of 3 can earn and be eligible for Medicaid) but less than $2,072/month (the minimum income required for subsidies in a marketplace (“Obamacare”) plan, he falls in the “coverage gap.” This gap exists in Florida and 9 other states that have refused to expand Medicaid. To recap: the 2010 Affordable Care Act provided 2 paths to affordable coverage: subsidies for those low-to-moderate income families earning between 100% and 400% of poverty (between about $ 2000 and $ 8300/month for a family of 3). Second, it required states to greatly expand their Medicaid programs to cover any low income uninsured adults. But in 2012 the Supreme Court ruled that Medicaid expansion would not be required; instead, each state could decide.

Thus, if Florida had expanded Medicaid, both Melissa and James would simply remain on Medicaid when their case is redetermined. Instead, Melissa will need to continually inform her providers that they cannot charge her copayments, and James will join the ranks of uninsured older Floridians.