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.

This article will explain what Florida Medicaid's "Share of Cost" program is, how it works, and what you need to know in order to maintain your benefits.

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

Note that although this article is about the specifics of Florida's program, 33 other states have similar medically needy pathways to Medicaid eligibility for people with high medical costs relative to their income.

Florida Share of Cost Basics

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

Since you don't meet the eligibility rules to qualify for Medicaid without using the share of cost program, you'll 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. Here's a website that has location information for the in-person service centers, as well as fax/mail information.

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.

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 healthcare 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 healthcare 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 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 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 significant 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 their 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

Depending on the area, it can be hard to find healthcare providers who will accept Florida Medicaid's 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 healthcare 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 healthcare costs down.

Option to Enroll in Other Coverage

If you're eligible to enroll in an employer's health plan or a subsidized individual/family health plan through Florida's exchange/Marketplace (HealthCare.gov), it might be a more manageable option than relying on Florida Medicaid's Share of Cost program.

Enrolling in an employer's plan or an individual/family plan will mean that you just have consistent coverage throughout the year, without having to submit your medical costs in order to keep qualifying for coverage each month.

If you're eligible for an employer's health plan, you can enroll in it regardless of whether you're eligible for any type of Medicaid.

If you're eligible for Medicaid under the regular eligibility guidelines (ie, not having to re-qualify each month via the share-of-cost program), you won't be eligible for premium subsidies to purchase individual coverage through Florida's exchange.

But if you would only qualify for Medicaid using the share-of-cost program, you can potentially qualify for a subsidy to offset the cost of coverage (and possibly also reduced out-of-pocket costs) if you enroll in a private plan through Florida's exchange.

Because Florida has not expanded Medicaid under the ACA, premium subsidy eligibility starts at 100% of the prior year's poverty level for Florida adults. So for 2024 coverage, a single adult can qualify for premium subsidies and cost-sharing reductions through Florida's exchange if their annual income is at least $14,580.

With an income that low, a person would be eligible for subsidies that cover the entire cost of some of the available health plans. And they would also be eligible for very robust cost-sharing reductions, making health care costs much more manageable than they would otherwise be with private coverage.

As income levels increase, premium subsidy amounts decline. And cost-sharing reduction eligibility ends altogether after a person's income exceeds 250% of the poverty level.

But if you're eligible for significant subsidies in the Florida exchange, a private plan might give you more peace of mind than having to requalify each month for coverage under Florida Medicaid's share-of-cost program.

Summary

Florida Medicaid's "Share of Cost" program is the state's Medically Needy eligibility pathway for Medicaid. It allows some people with high medical costs to access Medicaid even if their income is too high to qualify for full Medicaid under the state's normal rules.

Under Florida's Share of Cost program, a person submits their medical costs to the state each month, and Medicaid coverage kicks in once the costs have reached a certain amount. The person then has Medicaid coverage for the rest of the month, but the program resets on the first day of each new month.

Florida Medicaid will pay medical expenses that are incurred on the day that the person's medical expenses reach their share of cost amount, and on any remaining days in the month.

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 the expenses you have to cover yourself. If you have questions, call the Florida Medicaid office and ask them to explain the details. And remember that you can ask a friend or loved one to be part of that conversation, to help ensure that you understand everything that's explained. Especially when you're dealing with significant medical needs, it can be challenging to figure out all the administrative details on your own.