Medicaid: Medically Needy With a Share of Cost
Authored By: Community Legal Services of Mid-Florida
What is the Medically Needy Program? +
Medically Needy is a Medicaid program that can help pay for Medicaid-covered services. Individuals enrolled in the Medically Needy Program have income or assets that exceed the limits for regular Medicaid. A certain amount of medical bills must be incurred each month before Medicaid is approved. This is referred to as your “share of cost.”
What is “Share of Cost”? +
Your share of cost is the amount of medical bills that you must have before Medicaid can pay any of your other incurred medical bills for you. Your share of cost works like a deductible on a health insurance policy. It is based on the amount of your monthly income. You must have allowable medical expenses equal to the amount of your share of cost each month before you can become eligible for Medicaid for the rest of the month.
How does it work? +
Each month certain medical expenses, called “allowable medical expenses” that you owe or have paid during the month are counted toward your share of cost. When the amount of allowable medical expenses is equal to your share of cost for a month, you will be eligible for Medicaid for the rest of that month. Before using any medical services, you must be sure the provider is a Medicaid provider and willing to accept Medicaid as payment.
The following example is how the share of cost works: If your share of cost is $800 and you go to the hospital on May 10th and receive a bill for $1000, you have met the share of cost and Medicaid eligible from May 10th through May 31st. If the bill from May 10th is a Medicaid covered service received from a Medicaid provider, Medicaid will pay the bill and all other Medicaid covered expenses for the rest of the month. You may also be able to use medical expenses from a prior month to meet your share of cost. However, you will only be covered from the date of the actual expense that satisfies the share of cost. What this means is that Medicaid will not pay for the earlier expense because it was incurred before you met your share of cost.
It is to your benefit to schedule your most expensive treatment or service as early in the month as possible if it will satisfy your share of cost. For example, if you have an $800 share of cost and you go to the doctor on the 1st of the month where you incur a $75 bill, then on the 5th, you pick up your prescriptions which total $1,000, you do not meet your share of cost until the 5th . Medicaid will pay for your prescriptions but not your doctor visit from the 1st. If you had scheduled the pharmacy pick up before the doctor visit, all would be covered.
What are Allowable Expenses? +
Allowable medical expenses are bills that:
- Are unpaid and still owed and have not been used in an earlier month to meet your share of cost.
- Are paid during the current month.
- Have not been paid for you or will not be paid by health insurance, another person or any other source.
There are two kinds of allowable medical expenses: health insurance costs and medical service costs including Medicare premiums, Other health insurance premiums, including HMO and prepaid plan premiums and Coinsurance payments.
Medical service costs include personal care services prescribed by a doctor. Transportation by ambulance, bus or taxi to get medical care.
What Medical Expenses cannot be used to meet your share of cost? +
Premiums for insurance policies that pay you money because you are in the hospital or when the payment is not medical expenses, fist aid supplies and medicine chest supplies such as adhesive bandages, alcohol, cold remedies, etc.
What do I need to do? +
You need to provide proof of your medical expenses to an Economic Self-Sufficiency office (or Bill Tracking). You or your Medicaid provider can do this by fax, mail, or in person. Please include the amount of the expense, the date the expense was incurred and the date and amount of any payments that you have made for the expense. There are several kinds of proof you can provide, such as monthly medical bills you have received, receipts for paid medical bills and cancelled checks for paid medical bills. Obtain and submit your medical bulls as early in the month as possible to allow you maximum coverage for Medicaid that month.
What if I believe DCF has made an error in calculating my share of cost? +
You can fax the caseworker on your Notice of Case Action and request an explanation of your share of cost and why it is so high. If you are not satisfied with the response or get no response in a reasonable time, you can request a Fair Hearing. You have a right to request a Fair Hearing any time the Department issues a decision which is detrimental to you. You have 90 days to request a Fair Hearing. We recommend that you submit your request in writing to the Office of Appeal Hearings, Bldg. 5, Room 203, 1317 Winewood Blvd., Tallahassee, FL 32399.