The Florida Medicaid program offers a pathway to coverage known as the Medically Needy Program, which is designed for individuals whose income is above the standard Medicaid limit but who have significant medical expenses. This program introduces the concept of a “Share of Cost” (SOC), which functions much like a monthly deductible the applicant must meet before Medicaid benefits begin. The SOC represents a mandatory monthly expense threshold that the applicant must satisfy to activate their coverage for that month. By allowing applicants to “spend down” their income on qualified medical expenses, the program ensures access assistance.
Defining and Calculating the Share of Cost
The Share of Cost is the dollar amount an applicant must incur in medical expenses each month to become eligible for Florida Medicaid. This amount is calculated by the Department of Children and Families (DCF) and is based on the applicant’s countable monthly income and household size.
The calculation begins with the applicant’s gross monthly income, which is then reduced by certain allowable deductions, such as health insurance premiums or, in some cases, an allowance for a spouse. The resulting net income is compared to the state-established Medically Needy Income Level (MNIL).
For a single applicant, the MNIL in Florida is a very low figure, such as $180 per month, though this number changes annually. The SOC is the difference between the applicant’s countable net income and this MNIL, representing the amount of “excess” income that must be offset by medical bills.
For example, if an applicant’s net countable income is $690 per month and the MNIL is $180, their calculated Share of Cost would be $510. This figure is not a bill paid to the state; it is the threshold of medical expenses the individual must be responsible for before Medicaid coverage “kicks in” for that specific month. The higher an individual’s income above the MNIL, the higher their monthly SOC will be.
Meeting the Monthly Spend-Down Requirement
Once the monthly Share of Cost is determined, the applicant must engage in a process called “spend-down” to fulfill this obligation. The spend-down is met by incurring or accumulating qualified medical expenses that equal or exceed the calculated SOC for that calendar month. The expenses do not necessarily have to be paid by the applicant; they only need to be owed to a provider.
Qualified expenses are broad and include services prescribed by a doctor, hospital stays, prescriptions, co-payments, and transportation costs to medical appointments. Unpaid medical bills from previous months that have not been used toward a prior spend-down can also be applied to the current month’s SOC. Medical bills paid within the last three months may also be considered, as can health insurance premiums.
The Department of Children and Families requires documentation to prove the spend-down has been met. Applicants must submit proof of these medical expenses, which can include medical bills, receipts, or canceled checks, through the MyACCESS portal, by fax, or in person. Submitting documentation promptly is important, as the coverage activation timeline depends on the agency verifying the expenses.
Activating Medicaid Coverage
The activation of Medicaid coverage is directly tied to the date the monthly Share of Cost is met. As soon as the accumulated and verified medical expenses equal or exceed the calculated SOC, Medicaid coverage is activated. This coverage is not continuous throughout the month but begins retroactively from the date the spend-down threshold was crossed.
For the remainder of that calendar month, the individual is considered income-eligible for full Medicaid benefits, and the program will cover eligible medical services. This includes the portion of the medical bill that actually met the SOC, provided the service was incurred on or after the date the spend-down was met and the provider accepts Medicaid.
If an individual fails to meet their SOC in a given month, they do not receive Medicaid coverage for that period. The applicant’s enrollment in the Medically Needy Program is not terminated if they miss a month. Because the eligibility is determined monthly, the person must re-qualify by meeting the spend-down requirement every 30 days.