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 miss out on Medicaid coverage you could've received.

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

You have to meet all of the standard Medicaid eligibility requirements except the income requirement and also incur significant medical expenses each month.

So the program essentially allows you to subtract your medical expenses from your income and qualify for Medicaid if and when your medical expenses reach a certain amount. The program resets each month.

Share-of-Cost Basics

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 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.

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, Medicaid pays for your health care expenses for the rest of that month, and it also pays 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:

• Cindy has a $1,000 share-of-cost (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 it's aware she's accumulated $200 toward her $1,000 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 $1,100 in healthcare expenses for the month, which is more than her $1,000 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's lower reimbursement rates). Medicaid will also pay expenses for care that Cindy receives during the rest of the month.

However, 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 because she met her share-of-cost.

Your share-of-cost amount can be from providers that do or don't accept Medicaid. However, the costs on the day 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 accept Medicaid.

Eligible Expenses

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.

Maximizing 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 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, and which expenses are more than 90 days old and 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.

Does It Work Well?

Medicaid's 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

Florida's Medically Needy program has three big problems.

Hard to Understand

First, many Florida Medicaid Share-of-Cost beneficiaries don’t understand the program.

Some people mistakenly believe they have to pay their full share-of-cost out-of-pocket every month. They struggle to pay their share-of-cost themselves, thus paying more than was expected of them.

Some people mistakenly believe they won’t have coverage until they pay the share-of-cost every month, which they can't afford to do. They end up paying too much out-of-pocket and getting very few days of full Medicaid coverage.

Providers Don't Accept It

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 coverage is in effect.

Incentive to Use Services

Because eligibility resets every month, the Florida Medicaid Share-of-Cost program encourages you to use as many health care services as possible. The more bills you rack up, the more likely you are to have coverage that month.

That means there’s no incentive for you to keep health care costs down.

A Word From Verywell

If you're eligible for this program, be sure you understand all the conditions so you can maximize your health care while minimizing expenses you have to cover yourself.