Medicaid
Medicaid is the state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid is different in every state.
Florida Medicaid
Florida implemented the Medicaid Program on January 1, 1970, to provide medical services to indigent people. Over the years, the Florida Legislature has authorized Medicaid reimbursement for additional services. A major expansion occurred in 1989, when the United States Congress mandated that states provide all Medicaid services allowable under the Social Security Act to children under the age of 21.
Eligibility for Medicaid Services
Recipient eligibility for Medicaid is determined by the Department of Children and Families (DCF), Office of Economic Self Sufficiency. DCF determines Medicaid eligibility for:
- Low income families with children
- Children only
- Pregnant women
- Non-citizens with medical emergencies
- Aged and/or disabled individuals not currently receiving Supplemental Security Income (SSI)
How to Apply
There are three ways to apply for pregnancy Medicaid:
- Presumptively Eligible Pregnant Women (PEPW) – Pregnant women may go to a Qualified Designated Provider (QDP) to receive temporary Medicaid coverage for their prenatal care, usually on the same day they apply.
- Simplified Eligibility for Pregnant Women (SEPW) – Sometimes called MomCare, this process was created in 2001 to allow eligible pregnant women to be approved for full Medicaid coverage quickly and simply.
- ACCESS Florida Application – If the pregnant woman wishes to receive other benefits, such as cash, food stamps or benefits for other family members, she must complete a “regular” paper ACCESS Florida Application (AFA) or web application. Normal processing guidelines apply.
Application Forms
- Presumptive Eligibility for Pregnant Women (PEPW)
- Simplified Eligibility for Pregnant Women (SEPW)
- Other Medicaid, including Medically Needy
Where to Apply
- Presumptive Eligibility for Pregnant Women (PEPW): At a Qualified Designated Provider (QDP).
- Simplified Eligibility for Pregnant Women (SEPW): At a DCF ACCESS office in person, by mail or by fax.
- Other Medicaid, including Medically Needy: At a DCF ACCESS office in person, on-line, by mail or by fax.
- County Public Health Units (CPHU) (aka: County Health Departments): See listings Florida Department of Health
- Children’s Medicaid Services (CMS): See listings CMS Programs — Children’s Medical Services Homepage
- Regional Perinatal Intensive Care Centers (RPICC) (i.e., certain designated regional hospitals): See listings CMS RPICC Family Brochure Information
Extent of Medicaid Coverage
- Presumptive Eligibility for Pregnant Women (PEPW) – Limited Coverage:
Covers the pregnant woman only.
Covers pregnancy related outpatient services and prescriptions only.
Only one presumptive period per pregnancy allowed. - Simplified Eligibility for Pregnant Women (SEPW) – Full Coverage:
Covers the pregnant woman only.
Covers all Medicaid services, including inpatient services and delivery. - Other Medicaid, including Medically Needy – Full Coverage:
Covers all Medicaid services for all eligible household members, if requested.
Duration of Medicaid Coverage
- Presumptive Eligibility for Pregnant Women (PEPW)
- Begins the date of application and lasts until DCF makes a determination of ongoing eligibility, or 60 days (whichever is less).
- Simplified Eligibility for Pregnant Women (SEPW)
- Begins the first day of the application month and lasts through two (2) post-partum months. Lasts up to three (3) months retroactive coverage available, if eligible and requested, provided woman was pregnant during the retroactive period.
- Other Medicaid, including Medically Needy
- Other Medicaid: Begins the first day of the application month and lasts through two (2) post-partum months.
- Medically Needy: Begins the date that Share of Cost is met.
- Up to three (3) months retroactive coverage available, if eligible and requested.
U.S. Citizenship and Identity Verification Policy for Medicaid
- This policy does not apply to PEPW
- Most individuals who indicate they are U.S. citizens on the application must provide verification of their citizenship and identity.
- Exceptions: Individuals who are:
- SSI recipients
- Social Security Disability (SSDI) recipients
- Children in state foster care or adoption
- Medicare (any part) recipients
- Medicaid cannot be authorized prior to receipt of verification
Medicaid Family Planning Waiver
What is the Medicaid the Family Planning Waiver?
Professionals suggest that waiting at least two years between pregnancies is better for a woman and her baby’s health. The Medicaid Family Planning Waiver is a program which provides family planning services (services that help prevent, delay or plan a pregnancy).
What services are covered by this program?
This program provides family planning services for up to two years and includes:
- A family planning check-up and pap smear
- Access to different types of birth control
- Limited testing and treatment for Sexually Transmitted Diseases (STDs) and other gynecological problems
- HIV testing
- Tubal ligation (permanent surgery to prevent pregnancy)
- Pregnancy testing
Am I eligible?
To qualify for this program a woman must:
- Lose full Medicaid benefits or have lost them within the past 2 years
- Want to have family planning services
- Be 14 to 55 years of age
- Not be pregnant
- Be a United States citizen or eligible resident
- Not have had surgery which prevents pregnancy (tubal ligation–”tubes tied”– or hysterectomy)
- Have a household income within 150% – 185% of poverty guidelines (approximately $30,975 – $38,200 for a family of four)
Note: Women on SOBRA Medicaid since September 1, 2006 are automatically enrolled for one year, then must reapply for year two.
How do I apply?
To request an application by mail or find out more about eligibility, call the Florida Department of Health in Miami-Dade County at 305-325-2758. To download the form, click on the link found to the left.
Where can I get services?
Ask your current doctor, nurse or midwife if they provide Medicaid Family Planning Waiver Program services.
Medicaid for Children
The State of Florida has several programs designed to provide Medicaid for children only. The income limits for most of these programs vary based on the age of the child. Only the income of the child and parent(s) is counted when determining the child’s eligibility.
Families that wish to apply for Medicaid just for their children may do so through the KidCare program. The KidCare application can be mailed in and does not require an interview with the Department of Children and Families (DCF). Children who do not qualify for Medicaid may be eligible for other KidCare coverage if income is less than 200% of the Federal Poverty Level and will be referred to Florida Healthy Kids for this determination. To apply for KidCare, click the link to be directed to their website.
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