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Florida Medicaid Share of Cost—How Does it Work?

Understand this confusing program to maximize your benefits without going broke

By

Updated July 09, 2014

If you're enrolled in the Florida Medicaid 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 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.

How much is the 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.

What’s the relevance of the share of cost?

Your share of cost is the amount of healthcare 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, you notify Florida Medicaid of the expense, and keep track of a running total for the month.

The day your healthcare 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 healthcare expenses exceed your share of cost.

Do I have to pay my share of cost each month before Medicaid kicks in?

No!

You don’t actually have to pay the healthcare expenses used to reach your share of cost. You just have to owe that much.

When Medicaid coverage begins, not only does Medicaid pay for your healthcare expenses for the rest of that month, it also pays for the expenses used to meet your share of cost that month. 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:

Cindy has a doctor’s appointment on May 1 that 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, $100 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 retro-active to May 4.

Medicaid now pays all of the unpaid expenses used to meet Cindy’s share of cost for the month: the lab bill as well as the bill for the doctor’s appointment on May 1. Additionally, Medicaid will provide Cindy health insurance coverage for the rest of the month.

What can I use to meet my share of cost?

You can use healthcare expenses that would normally be covered by Medicaid if you had Medicaid coverage. You may use expenses from up to 90 days ago.

The healthcare expenses don’t necessarily have to be for you. You can use healthcare 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.

How do I maximize benefits?

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

  • Notify Medicaid of your healthcare expenses.
  • 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 $3000 every month, and your share of cost is $1900, 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.

What are the biggest problems with Florida Medicaid Share of Cost?

There are three big problems:

  1. 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.

  2. 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 accept Medicaid Share of Cost. If a provider checks your Medicaid eligibility before your appointment and finds you’re not enrolled because you haven’t met your share of cost for the month, they might request payment in full at the time of service. If you pay them, you won’t be reimbursed by Medicaid. But, if you don’t pay them, they could refuse to provide the service.

  3. This taxpayer-funded program is fiscally irresponsible. The design of the Florida Medicaid Share of Cost program encourages you to use as many healthcare 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 healthcare costs down. However, changes may be coming as Florida looks for ways to move its Medicaid recipients into managed care.

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