How Florida Medicaid Share of Cost Works

 If you're enrolled in the Florida Medicaid Medically Needy Share of Cost program, you need to know how to use this complicated health insurance correctly. If you use it incorrectly, you’ll pay more than necessary, or you’ll miss out on Medicaid coverage you could have received.

In Florida, the Medicaid Share of Cost program is a type of health insurance for the medically needy. These are people who make too much money to qualify for regular Medicaid, but not enough money to pay for their healthcare needs.

They meet all of the standard Medicaid eligibility requirements except the income requirement, but they also incur significant medical expenses each month. So the program essentially allows people to subtract their medical expenses from their income and qualify for Medicaid if and when their medical expenses reach a certain amount. The program resets each month.

Basics of Share of Cost

Your share of cost is the amount of health care expenses you must incur before Medicaid coverage kicks in for the month.

You start each month without Medicaid health insurance coverage. Each time you have a healthcare expense (including health insurance premiums, out-of-pocket medical costs, transportation costs to and from medical appointments, etc. ), you notify Florida Medicaid of the expense (by fax, mail, or in-person) and keep track of a running total for the month.

The day your health care expenses for the month exceed your share of cost, your Medicaid coverage begins. From that day until the end of the month, you have full Medicaid coverage. On the first day of the next month, you’re again without coverage until your health care expenses exceed your share of cost. Other states have different approaches to Medically Needy Medicaid eligibility. New Jersey, for example, determines eligibility six months at a time. But in Florida, eligibility for the Medically Needy Medicaid program starts over each month.

Your Share of Cost Amount

When you get the notice that you’re accepted into the Medically Needy Program, it will tell you your monthly share of cost. This amount is related to how much your income exceeds the traditional Medicaid income limits. The more money you make, the more your share of cost will be. If your household income changes, or if the number of people in your household changes, your share of cost will also change.

When You Must Pay Your Share of Cost

You don’t actually have to pay the health care expenses used to reach your share of cost. You just have to owe that much. But you can only use a particular medical bill one time; you cannot continue to use the same medical debt month after month to meet the share of cost requirements.

When Medicaid coverage begins, not only does Medicaid pay for your health care expenses for the rest of that month, it also pays for the expenses used to meet your share of cost that month, if they were incurred on or after the date that your Medicaid coverage begins. If you choose to pay those expenses yourself, they’ll still count toward meeting your share of cost, but you won’t be reimbursed by Medicaid for what you’ve paid.

Here’s an example using Cindy and her $1000 share of cost (that amount is unique to Cindy, based on her household size and monthly income):

Cindy has a doctor’s appointment on May 1 which results in a bill of $200. She faxes the bill to Florida Medicaid so Medicaid is aware that she has accumulated $200 toward her $1000 share of cost for May. Medicaid doesn’t pay the bill since Cindy hasn’t met her share of cost for the month yet.

Cindy has blood tests on May 4, gets a bill from the lab for $900, and faxes that bill to Medicaid. Between her doctor visit and her blood tests, she’s now accumulated $1100 in healthcare expenses for the month, which is more than her $1000 share of cost.

Since Cindy’s total monthly expenses exceeded her share of cost on May 4, her full Medicaid coverage begins on May 4 and continues through the end of May. Although it may take a few days for Medicaid to process Cindy’s expenses and grant the Medicaid coverage, the coverage will be retroactive to May 4.

Medicaid now pays Cindy's medical expenses from May 4 through the end of the month. That means they'll pay the $900 bill from the lab (assuming the lab accepts Medicaid, which means they'll have to accept far less than $900 as payment in full, since Medicaid has lower reimbursement rates). Medicaid will also pay expenses for care that Cindy receives during the rest of the month. But Medicaid will not pay for the doctor's appointment that Cindy had on May 1, since her Medicaid coverage didn't take effect until May 4.

As you can see in the example above, Cindy incurred a large bill from the lab on May 4. If the lab didn't accept Medicaid, she'd have been stuck with the lab bill, even though her Medicaid coverage took effect that day (when she met her share of cost). Your share of cost amount can be from providers that do or don't accept Medicaid. But the costs on the day that your share of cost goes over the required amount for Medicaid eligibility will only be covered by Medicaid if the providers you use that day are willing to accept Medicaid.

Expenses That Can Meet Share of Cost

You can use health care expenses that would normally be covered by Medicaid if you had Medicaid coverage. You may use expenses from up to 90 days ago. The amount you paid for health insurance premiums (not counting fixed indemnity plans) can count towards your share of cost, and so can transportation costs (by ambulance, bus, or taxi) incurred for you to get to a medical facility.

The medical expenses don’t necessarily have to be for you. You can use medical expenses for anyone whose income was included in determining your Medicaid eligibility. In the above example, if Cindy’s husband’s income was included in Cindy’s Medicaid eligibility determination, Cindy could use her husband’s healthcare expenses toward her own share of cost. 

However, you can’t use an expense that’s more than 90 days old. And, you can’t use an expense that was used to meet a share of cost for an earlier month. Florida Medicaid also notes that you can't count expenses for over-the-counter medications or supplies.

How Do I Maximize Benefits?

You’ll have to be organized to maximize your Medicaid coverage.

• Notify Medicaid of your healthcare expenses, via mail, fax, or in-person.
• Time appointments and expenses for early in the month so that you meet your share of cost sooner rather than later in the month. This will help you get more days of full Medicaid benefit coverage.
• Keep track of a running total of healthcare expenses until you exceed your share of cost each month.
• Be aware of which healthcare expenses have already been used to meet a prior month’s share of cost, which expenses haven’t been used yet, as well as which expenses are more than 90 days old so can’t be used to meet your current share of cost.
• You’ll need to pay any healthcare expenses that are more than 90 days old, haven’t been used to meet any month’s share of cost, and weren’t received while you had Medicaid coverage.

Is There Anyone this Complicated System Actually Works Well For?

Medicaid share of Cost works especially well for people with high healthcare expenses that recur every month. For example, if you’re on a medication that costs $3,000 every month, and your share of cost is $1,900, you’ll meet your share of cost every month when you refill your prescription. Time your refills to the first day of every month, and you’ll be covered with full Medicaid benefits all month every month.

Problems With Florida Medicaid Share of Cost

There are three big problems with Florida's Medically Needy program.

Many Florida Medicaid Share of Cost beneficiaries don’t understand the program. They mistakenly believe that they have to pay their full share of cost out-of-pocket every month. They struggle to pay their share of cost themselves, resulting in paying more than was expected of them. Or, they become disheartened since they can’t afford to pay the share of cost every month, and they mistakenly believe they won’t have coverage until they pay. They don’t see the value of the benefit, pay too much out-of-pocket, and end up getting very few days of full Medicaid coverage.

It’s hard to find healthcare providers who will accept Medicaid Share of Cost program beneficiaries. Even providers who accept regular Medicaid sometimes won’t agree to see a patient in the Medically Needy program until the person's share of cost has been met for the month and their Medicaid coverage is officially in effect.

Unfortunately, the design of the Florida Medicaid Share of Cost program, including the fact that eligibility resets every month, encourages you to use as many health care services as possible. The more bills you rack up, the more likely you are to have health insurance coverage that month. There’s no incentive to keep health care costs down.