What is Medicaid?

Medicaid is a program that helps pay for medical care for people with low incomes. It is run by both the state and the federal government. Medicaid helps people who might not be able to get medical care otherwise, including kids, the elderly, and people with disabilities who need help paying for nursing homes and other long-term care. In Florida, Medicaid is managed by a program called Statewide Medicaid Managed Care (SMMC). This program has three main parts:

1. Managed Medical Assistance (MMA): This covers regular medical services like doctor visits, hospital stays, prescribed medications, mental health care, family planning, home health care, nursing homes, hospice care, vision, dental care, and transportation to medical appointments. Most people with Medicaid use this service. You can pick your MMA plan when you first sign up for Medicaid or within 120 days after. If you applied for Medicaid through the Florida Department of Children and Families (DCF), and don’t pick a plan, one will be chosen for you.

2. Long-Term Care (LTC): This helps with costs if you need care in a nursing home, assisted living facility, or at home. To get LTC, you need to be at least 18 years old and need care similar to what you’d get in a nursing home or hospital. The State of Florida will send you information about how to choose a plan. You need to pick a plan by the date mentioned in the letter. You can call (877) 711-3662 for help choosing a plan, and if you need more help, you can even ask for a face-to-face meeting.

3. Dental: This covers all dental care for both kids and adults. Everyone on Medicaid must sign up for a dental plan. The State of Florida will let you know which of the three dental insurance companies they have assigned you to.

You can only have Medicaid in one state at a time because each state has its own rules. If you move to Florida, you can apply for Medicaid right away. Make sure to plan ahead and apply quickly to avoid losing your benefits. This is especially important because as of February 1, 2019, Florida no longer offers retroactive Medicaid coverage except for pregnant women under 21. If you had Medicaid in another state, it will stop when you apply for Medicaid in Florida.

Medicaid Eligibility

In Florida, if you get cash benefits from the Social Security Administration’s (SSA) Supplemental Security Income (SSI) Program, you automatically qualify for Medicaid. You don’t have to apply for Medicaid separately. When the SSI cash benefits terminate, the individual may be entitled to additional months of Medicaid coverage. If the SSI terminates, Medicaid coverage will continue for two months beyond the SSI payment end date to allow time for DCF to review eligibility under other coverage groups.

If you are receiving SSI cash benefits in another state that does not automatically qualify you for Medicaid and you move to Florida, you should contact your local Social Security and notify them that you should now qualify for Florida Medicaid. Be prepared to show your proof of residency. Here are the local Social Security offices serving The Villages.

Lake & Sumter County Office: 900 N. 14th Street, Suite 100, Leesburg, FL 34748
Phone: (866) 836-3623

Marion County Office: 933 E. Silver Springs Blvd., Ocala, FL 34470
Phone: (877) 626-9911

If you are not receiving SSI cash benefits, you apply for Medicaid through DCF. To qualify you must be a Florida resident and either a U.S. citizen, permanent resident, or legal alien. You must need help with health care, and your yearly income before taxes must be below established limits. You can qualify if you are pregnant, taking care of a child who is 18 or younger, are blind, have a disability or have a family member with a disability, or are 65 or older. Click here to determine your Medicaid eligibility

Applying for Medicaid

These documents are required when applying for Medicaid:

• Social Security Number
• Date of birth
• Proof of identity
• Proof of citizenship
• Income verification, including, but is not limited to, income from a job or self-employment, child support or alimony payments, pensions, etc.
• List of expenses for housing, utilities, a business or self-employment, food, clothing, etc.
• Information on all assets such as bank accounts, investments, trust funds, vehicles, property, or life/health insurance

You can apply for Medicaid in several ways. You can do it online, use the DCF automated phone system by calling (850) 300-4323, send it through the mail, or go to your local DCF office in person. Whichever method you choose make sure to keep copies of everything you send or submit.

According to DCF the easiest way is to apply online on the DCF Automated Community Connection to Economic Self Sufficiency (ACCESS) Florida website. First, you need to create a MyAccess account. If you want to apply by mail, you should download the Access Florida Application, fill it out and send it, along with all required documents, to the ACCESS Central Mail Center at P.O. Box 1770, Ocala, FL, 34478-1770.

Applying in person might be a good idea because Medicaid applications have strict deadlines and an in-person interview is usually required anyway. Here are the local DCF offices serving The Villages:

Lake County Office: 1300 Duncan Drive, Tavares, FL, 32778
Phone: (352) 742-6330 

Marion County Office: 3895 SW 13th St, Ocala, FL 34474
Phone: (866) 762-2237

Sumter County Office: 901 Industrial Drive, Suite #110, Wildwood, FL 34785
Phone: (352) 330-2162

You can check your case status anytime by logging into your MyACCESS Account, or by calling the DCF automated telephone response system. While checking your case status you can also perform these actions:

• View when the next renewal is scheduled
• Complete an annual renewal
• View a list of items needed to process the application or renewal
• View the date and time of a scheduled appointment
• View the Share of Cost amount if enrolled in Medically Needy
• View the amount of the patient responsibility
• Print a temporary Medicaid card
• Upload and view documents
• Report household changes

Additional Available Services

When applying for Medicaid you can also apply for food and cash assistance. If you meet Florida Medicaid qualifications, you likely also meet the requirements for these programs too. You do not need to fill out multiple applications to be considered for these services. Click here to learn more about these additional services.

Application Timeframe

Applications for Medicaid in Florida are approved within 45 days, or as long as 90 days based on disability, after all information needed to make a determination is available. You will be notified by letter of your Medicaid eligibility and the level of coverage you will receive.

Renewal

Medicaid benefits are renewed each year. You should receive a letter from DCF 45 days before your Medicaid anniversary explaining how to verify your Medicaid eligibility. It is very important that you confirm your eligibility in your renewal month, not before or after. If you don’t verify your Medicaid eligibility on time, you will lose your Medicaid benefits and will need to reapply.

Medicaid Gold Card

The Florida Medicaid Gold Card is a special ID card given to people who qualify for Florida Medicaid. It helps them get medical care and other health services easily.

You don’t apply for the Gold Card directly. Instead, it’s given to people who use Medicaid services correctly and follow the rules. It shows that they are using the Medicaid program properly. The Gold Card has many benefits to encourage people to use their Medicaid services well. By meeting the eligibility rules and using the services responsibly, people can keep getting the benefits of the Gold Card.

The Florida Medicaid Gold Card offers several benefits, including:

• Health and Dental Plan Enrollment: Most Medicaid recipients are required to enroll in specific health and dental plans. The Gold Card facilitates access to these plans and allows you to change your plan within 120 days of enrollment if needed.

• Service Accessibility: For information on providers and covered services, With your Gold Card you can directly contact your plan or the Medicaid Helpline. This ensures that you have the necessary information to make informed healthcare decisions.

• Identification and Eligibility Verification: The Gold Card includes a unique Card Control Number, allowing healthcare providers to verify your eligibility. However, it’s important to note that the card does not display the Medicaid number itself.

• Permanent Identification: The Gold Card is your permanent identification for Medicaid. It stays valid even if you stop qualifying for Medicaid. This shows how important the card is for your healthcare..

• Protection and Usage: You should protect your Gold Card from damage and never lend it to anyone. It is essential to carry the Gold Card at all times, especially when accessing medical or dental care, to ensure seamless service delivery.

• Coordinated Coverage with Other Insurance: If you have other forms of insurance, you must inform your Medicaid provider, ensuring that all potential coverage options are utilized effectively.

• Out-of-State Coverage: The Gold Card can be used for emergency care and pre-approved care outside of Florida, showing that it’s useful even in other states.

• Rights and Responsibilities: You have the right to challenge any decision to deny, reduce, or stop services. You are also responsible for making sure the Gold Card is not used in the wrong way to help protect the Medicaid program.

• Comprehensive Coverage: The Florida Medicaid Gold Card provides comprehensive coverage for vital services such as doctor visits, hospital care, prescription drugs, and more.

Medicaid Redetermination

The COVID-19 pandemic created a public health emergency, and during that time, a lot more people asked for Medicare help. Federal law required states were required to provide continuous Medicaid coverage and didn’t remove anyone from the program. On March 31, 2023, the public health emergency ended, and the DCF started checking Medicaid recipients to see who was still eligible. Some cases were reviewed and approved automatically, but others needed more attention. Letters were sent to those people, asking for more information within 45 days.

If you get a letter from DCF about Medicaid Redetermination, they’re asking you to prove that you still need and qualify for Medicaid. The letter will tell you what documents or information you need to send in. This might include things like proof of income or changes in your family situation. It’s important to act quickly, and don’t miss the deadline, to make sure you continue getting the help you need for health care. Fill out any forms and gather the requested documents. Then, make copies and send everything back to the address given in the letter. Be sure to follow up if you don’t hear back within a few weeks.

How to File Complaints

The Florida Agency for Health Care Administration (AHCA) oversees the Florida Medicaid program, licenses and regulates health facilities in Florida, and provides information to residents about the quality of care they receive. If you or someone you know suspects Medicaid fraud or abuse, you can file a complaint with the relevant AHCA office.

Complaints may be filed anonymously. However, if you want to be informed of the results, be prepared to provide your name, address, and telephone number, allowing AHCA surveyors to contact you if additional information or clarification is needed.

When filing a complaint, be ready to provide specific details, such as patient or resident names, dates, times, and the location of the incident.

Once filed, your complaint is forwarded electronically to the AHCA Complaint Administration Unit for review and priority assessment. If AHCA determines it has the authority to conduct an inspection, the complaint will be scheduled for investigation. If there is an indication of immediate danger to residents, an inspection will be conducted within two business days. You will be notified in writing about the inspection’s outcome.

If AHCA decides not to conduct an inspection, you will receive a written explanation. In cases where another agency has authority over the complaint, AHCA will refer your information to them and inform you of this action. Due to Health Insurance Portability and Accountability Act (HIPAA) requirements, AHCA must remove identifying information before referral, which may limit the other agency’s ability to evaluate the complaint fully. You may be asked to forward your concerns directly to ensure all information remains intact.

Even if an inspection is not conducted, your concerns will be recorded and considered during future inspections.

You can track your complaint status with the AHCA complaint tracking tool using the complaint number provided when you filed.

Health Care Facility Complaints

If you suspect that a healthcare facility has violated laws related to your care or someone else’s care, you can file a complaint with AHCA. The process differs slightly depending on whether the facility is licensed by AHCA. If you are unsure of the facility’s licensing status, use AHCA’s Facility Locator Tool.

To file a complaint against a licensed healthcare facility, complete the Licensed Health Care Facility Complaint Form. For unlicensed facilities, use the Unlicensed Health Care Facility Complaint Form. If you prefer to file a quality-of-care complaint over the phone, call 1-888-419-3456, Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time.

Health Care Provider Complaints

To report a healthcare provider for potential disciplinary action, contact the Florida Health Medical Quality Assurance Board. They do not investigate complaints regarding fees, missed or broken appointments, customer service issues, bedside manner, rudeness, professionalism, or personality conflicts.

Medicaid Fraud and Abuse Complaints

If you suspect Medicaid fraud or abuse by a health plan, provider, or anyone billing Medicaid, use the Medicaid Fraud and Abuse Complaint Form to report it. Suspected Medicaid recipient fraud can also be reported to the Florida Department of Children and Families (DCF).

Statewide Medicaid Managed Care Complaints

You can file a consumer complaint against AHCA (Medicaid) in the following ways:

• Visit the Statewide Medicaid Managed Care complaint webpage and complete the complaint form.
• If you prefer to file by phone, call the Statewide Medicaid Managed Care complaint center at 1-877-254-1055 (TDD 1-866-467-4970), Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time.
• Write to the AHCA at P.O. Box 60127, Fort Myers, FL 33906.
• Email MedicaidHearingUnit@ahca.myflorida.com

The Florida Office of Inspector General at AHCA investigates complaints related to potential violations of agency policies, rules, or laws involving agency employees or contractors.

Civil Rights Compliance

If you believe you or someone else has experienced discrimination based on race, color, national origin, age, disability, or sex by AHCA or its contractors, you can file a complaint with AHCA.

AHCA Feedback

You can provide feedback to AHCA here.

Resources

‣ Statewide Medicaid Managed Care FAQ: www.flmedicaidmanagedcare.com/home/faq
‣ Medicaid FAQ: www.medicaid.gov/medicaid-and-you/index.html
‣ SMC website: www.flmedicaidmanagedcare.com/home/index
‣ DCF Medicaid website: www.myflfamilies.com/services/public-assistance/applying-for-assistance
‣ SSI-Related Medicaid Fact Sheet 2024: www.myflfamilies.com/sites/default/files/2023-02/ssifactsheet.pdf
‣ Florida Medicaid’s Covered Services and HCBS Waivers FAQ: ahca.myflorida.com/medicaid/medicaid-policy-quality-and-operations/medicaid-policy-and-quality/medicaid-policy/florida-medicaid-s-covered-services-and-hcbs-waivers
‣ Florida’s Medicaid Redetermination Plan: www.myflfamilies.com/floridas-medicaid-redetermination-plan-frequently-asked-questions
‣ Medicaid Homestead Exemption FAQ: aspe.hhs.gov/reports/medicaid-treatment-home-determining-eligibility-repayment-long-term-care-0
‣ FindHelp.org: www.findhelp.org/provider/florida-department-of-children-and-families–tavares-fl/4605950203789312?postal=32726
‣ File a complaint with ACHA: ahca.myflorida.com/contact-ahca/file-a-complaint