Fla. Stat. § 409.904 — Florida Code / Title XXX / Chapter 409 / Part III / Section 409.904
409.904 Optional payments for eligible persons.
Status: in_force

The agency may make payments for medical assistance and related services on behalf of the following persons who are determined to be eligible subject to the income, assets, and categorical eligibility tests set forth in federal and state law. Payment on behalf of these Medicaid eligible persons is subject to the availability of moneys and any limitations established by the General Appropriations Act or chapter 216.

(1)(a) Subject to federal waiver approval, a person who is age 65 or older or is determined to be disabled, whose income is at or below 88 percent of the federal poverty level, whose assets do not exceed established limitations, and who is not eligible for Medicare or, if eligible for Medicare, is also eligible for and receiving Medicaid-covered institutional care services, hospice services, or home and community-based services. The agency shall seek federal authorization through a waiver to provide this coverage. (b)1. A person who was initially determined eligible for Medicaid under paragraph (a) and is receiving Medicaid-covered institutional care services or hospice services, or a person who is receiving home and community-based services pursuant to s. 393.066 or s. 409.978, shall be presumed eligible for continued coverage for such Medicaid-covered services during any redetermination process, and the agency shall continue to make payments for such services, unless the person experiences a material change in his or her disability or economic status which results in a loss of eligibility. In the event of such a change in disability or economic status, the person or his or her designated caregiver or responsible party must notify the agency and the Department of Children and Families of such change, and the department may conduct a redetermination of eligibility. If such redetermination is conducted, the department must notify the person or his or her designated caregiver or responsible party before the commencement of the redetermination and, at its conclusion, the results of the redetermination. 2. The agency shall, no later than October 1, 2025, seek federal authorization to exempt a Medicaid-eligible disabled person from annual redetermination of eligibility pursuant to this paragraph. 3. The agency and the department shall develop a process to facilitate the notifications required under subparagraph 1.

(2) A family, a pregnant woman, a child under age 21, a person age 65 or over, or a blind or disabled person, who would be eligible under any group listed in s. 409.903(1), (2), or (3), except that the income or assets of such family or person exceed established limitations. For a family or person in one of these coverage groups, medical expenses are deductible from income in accordance with federal requirements in order to make a determination of eligibility. A family or person eligible under the coverage known as the “medically needy,” is eligible to receive the same services as other Medicaid recipients, with the exception of services in skilled nursing facilities and intermediate care facilities for the developmentally disabled.

(3) A person who is in need of the services of a licensed nursing facility, a licensed intermediate care facility for the developmentally disabled, or a state mental hospital, whose income does not exceed 300 percent of the SSI income standard, and who meets the assets standards established under federal and state law. In determining the person’s responsibility for the cost of care, the following amounts must be deducted from the person’s income: (a) The monthly personal allowance for residents as set based on appropriations. (b) The reasonable costs of medically necessary services and supplies that are not reimbursable by the Medicaid program. (c) The cost of premiums, copayments, coinsurance, and deductibles for supplemental health insurance.

(4) A low-income person who meets all other requirements for Medicaid eligibility except citizenship and who is in need of emergency medical services. The eligibility of such a recipient is limited to the period of the emergency, in accordance with federal regulations.

(5) Subject to specific federal authorization, a woman living in a family that has an income that is at or below 185 percent of the most current federal poverty level is eligible for family planning services as specified in s. 409.905(3) for a period of up to 24 months following a loss of Medicaid benefits.

(6) A child who has not attained the age of 19 who has been determined eligible for the Medicaid program is deemed to be eligible for a total of 6 months, regardless of changes in circumstances other than attainment of the maximum age. Effective January 1, 1999, a child who has not attained the age of 5 and who has been determined eligible for the Medicaid program is deemed to be eligible for a total of 12 months regardless of changes in circumstances other than attainment of the maximum age.

(7) A child under 1 year of age who lives in a family that has an income above 185 percent of the most recently published federal poverty level, but which is at or below 200 percent of such poverty level. In determining the eligibility of such child, an assets test is not required. A child who is eligible for Medicaid under this subsection must be offered the opportunity, subject to federal rules, to be made presumptively eligible.

(8) A child who has not attained 19 years of age and who, notwithstanding s. 414.095(3), would be eligible for Medicaid under s. 409.903, except that the child is a lawfully residing child as defined in s. 409.811. This subsection does not extend eligibility for optional Medicaid payments or related services to an undocumented immigrant.

(9) A Medicaid-eligible individual for the individual’s health insurance premiums, if the agency determines that such payments are cost-effective.

(10) Eligible women with incomes at or below 200 percent of the federal poverty level and under age 65, for cancer treatment pursuant to the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000, screened through the Mary Brogan Breast and Cervical Cancer Early Detection Program established under s. 381.93.

(11) Subject to federal waiver approval, a person diagnosed with acquired immune deficiency syndrome (AIDS) who has an AIDS-related opportunistic infection and is at risk of hospitalization as determined by the agency and whose income is at or below 300 percent of the Federal Benefit Rate.

(12) The agency shall make payments to Medicaid-covered services: (a) For eligible children and pregnant women, retroactive for a period of no more than 90 days before the month in which an application for Medicaid is submitted. (b) For eligible nonpregnant adults, retroactive to the first day of the month in which an application for Medicaid is submitted.

History: s. 33, ch. 91-282; s. 2, ch. 96-417; s. 11, ch. 97-263; s. 51, ch. 98-288; s. 9, ch. 2000-253; s. 2, ch. 2001-52; s. 1, ch. 2001-104; ss. 1, 2, ch. 2001-377; ss. 16, 17, ch. 2002-400; s. 1, ch. 2003-9; s. 8, ch. 2003-405; s. 51, ch. 2004-5; s. 7, ch. 2004-270; s. 5, ch. 2005-60; s. 9, ch. 2006-28; s. 3, ch. 2008-143; s. 4, ch. 2009-55; s. 4, ch. 2010-156; s. 3, ch. 2011-61; s. 7, ch. 2016-65; s. 6, ch. 2017-129; s. 24, ch. 2019-116; s. 16, ch. 2020-114; s. 6, ch. 2021-41; s. 11, ch. 2025-204.