Florida: Medicaid Buy-In Program

Florida: Medicaid Buy-In Program

Upshot

  • Three identical bills (H.R. 675, S.B 1692, and S.B. 1822) would narrowly expand Medicaid eligibility in Florida to individuals with disabilities ages 16-64 who are above current state Medicaid eligibility levels.

  • All three bills died at the committee level during the legislative session. Any efforts to expand Medicaid eligibility appears unlikely to advance under Republican control of the state legislature and governorship. A ballot initiative, though with its own set of challenges, is the more viable path forward to significantly expand Medicaid in Florida.

Background

Florida is one of 12 states that has not expanded Medicaid under the ACA to adults without dependent children. Therefore, most adults without dependent children are not eligible for Medicaid in Florida. The income eligibility limit for parents is 30 percent FPL. Efforts to expand Medicaid through voter initiatives have not been successful in Florida and have been further thwarted by the Florida Legislature. Notably, however, Florida has taken steps over the last several years to expand access to Medicaid for working people with disabilities who are not automatically eligible for Medicaid due to receipt of Supplemental Security Income (SSI) benefits – specifically, people with disabilities with an income above 200 percent FPL, the current income for SSI-related Medicaid benefits.

In 2018, the Florida Legislature directed the Agency for Health Care Administration (AHCA) to evaluate three options to allow individuals with disabilities to work and earn additional income while maintaining their Medicaid coverage. AHCA recommended that Florida pursue a state plan amendment to waive certain income and resource rules for individuals receiving services through home and community-based service waivers, as it would provide “the most direct path” to implementing a Working People with Disabilities program in Florida “while simultaneously imposing a low fiscal impact to the state and the least administrative burden.” AHCA also evaluated, but ultimately did not recommend, the following options:

  • Increase utilization of Miller Trusts/Qualified Income Trusts, which would allow eligible individuals to place sufficient income into a special account in order to meet the Medicaid income eligibility limits; and 

  • Implement a Medicaid buy-in program to allow eligible individuals with disabilities to pay a premium for Medicaid benefits.

The fiscal year 2019-2020 state budget included funding to implement the Working People with Disabilities program through a state plan amendment. Florida received federal approval to implement this program in 2020. As a result, people in Medicaid can qualify for the program if they are enrolled in one of the following home and community-based services waivers: Development Disabilities Individual Budgeting Waiver (iBudget); the Long-Term Care Waiver; and the Familial Dysautonomia Waiver. The Medicaid monthly income limit is 550 percent of the federal benefit rate (FBR) (previously 300 percent of FBR), and the asset limit to $13,000 for an individual and $24,000 for a couple (previously $2,000 for an individual and $3,000 for a couple). The iBudget and Familial Dysautonomia waivers are fee-for-service programs. The Long-Term Care Waiver is a capitated, managed care program offered by Statewide Medicaid Managed Care Long-term Care plans and Managed Medical Assistance Comprehensive plans.

Summary

The bill would require AHCA to establish and implement a Medicaid buy-in program, as authorized under the federal Ticket to Work and Work Incentives Improvement Act of 1999 and the Balanced Budget Act of 1997, for individuals with disabilities who are between 16 and 64 years and have a household income that exceeds the maximum limit for Medicaid eligibility. Any premium or cost-sharing would be limited to a certain percentage of an individual’s income. Program implementation would necessitate AHCA seek approval of a federal waiver or a state plan amendment.