The U.S. House proposal radically restructures and cuts federal funding for the Medicaid program. Florida would bear the brunt of one of the biggest costs shifts from the federal government to the state at the same time that expenditures are projected to exceed incoming revenue. And the health of already struggling Floridians will suffer.
House leaders recently released the outline of a plan to repeal and replace the Affordable Care Act (ACA). But the plan goes alarmingly far beyond this charge.
It includes a radical cut and restructuring of the Medicaid program through per capita caps. This would terminate open-ended federal Medicaid funding for states. The program, which has dependably taken care of the most vulnerable Floridians for nearly 50 years, will cease to exist.
Capped funding will inevitably translate into deep cuts to the Medicaid program, slashing coverage for seniors, people with disabilities, families and children.
The Medicaid program covers approximately 4 million Floridians – 20 percent of the total population. Beneficiaries include over 2 million children (47 percent of all Florida children), and 1.7 million adults – seniors, persons with disabilities, pregnant women and very low income parents. Program services include 63 percent of all babies delivered in the state as well as 61 percent of all nursing home days. The blanket of Medicaid coverage for Floridians is wide and crucial for their health and safety.
Under the proposed House plan, Florida would be on the short end of the one of the biggest costs shifts from the federal government to the state. Medicaid is the state’s number one source of federal funding. Federal dollars currently cover 61 cents of every state dollar spent on the program.  A majority of the funding (57 percent) covers persons with disabilities and seniors. The largest group of beneficiaries, children, consume only 27 percent of the Florida Medicaid budget.
A Medicaid cap or block grant would blow a huge hole in Florida’s budget. It is highly unlikely that the Governor or Florida Legislature would choose to fill that hole by cutting other state priorities such as education or transportation – or by raising taxes. Whether through a block grant or per capita caps, it’s just another way of putting the state on an inevitable path of deep cuts to the Medicaid program.
Adding to the “perfect storm” are Florida’s unique demographics. Consider these facts: Florida is one of the fastest growing states in the country. Since the 2010 census we have gained 1.4 million additional residents, including more families living in poverty., Our population continues to grow at a projected average rate of 320,871 net new residents per year. Florida’s older population (age 60 and older) will account for most of Florida’s population growth.
Florida already has the largest percentage of elderly residents in the nation.
The House’s proposed new funding scheme would also have particularly draconian consequences in Florida due to historical policy choices- Florida Medicaid is already one of the “leanest” programs in the country. Our annual per person Medicaid expenditure rate is in the bottom five states.
Per capita caps, the capped funding option promoted by Governor Scott, would lock in unsustainable funding levels that would diminish year after year. The pitfalls of per capita cap funding are already well documented. Caps are intentionally set below expected spending levels. Based on the House budget resolution passed in 2016, overall federal Medicaid spending would be reduced by 41 percent over the next decade. The indisputable “math” of per capita caps would result in declining resources to address Florida’s increasing needs.
Medicaid’s current funding structure gives the state flexibility to respond to unanticipated costs arising from public health emergencies (e.g., Zika, other new viruses, opioid addiction, HIV/AIDS) or new advances in medical care (e.g., life-saving Hepatitis C treatments). If Medicaid investments are made on the front end to promptly address these unexpected developments, it can save substantial state dollars in the long run. However, this flexibility would end under capped federal Medicaid funding.
Instead, under the House’s proposal, the state would have new “flexibility” to make deep cuts to the program wherever they choose. Essentially, the federal government would rip away the “blanket” of Medicaid coverage it has provided to our state residents and replace it with a handkerchief.
With an ever-shrinking Medicaid pie, Florida legislators would face gut-wrenching choices about how to cut their constituents’ Medicaid benefits. So, who and what to cut?
Even Governor Scott anticipates the dilemma of these challenging political choices. Remarkably, he is requesting from the federal government an increased Medicaid federal match (90 percent) for “vulnerable populations” – a cruel irony since he already passed up an even better deal for the state (and more than 500,000 uninsured Floridians) when he rejected Medicaid expansion. Notably, there is no such 90 percent match component in the House plan.
The House plan would be a giant step backwards in reaching the goal of a healthy and prosperous Florida. Instead, the proposal is all about saving the federal government money. It’s smoke and mirrors to frame it any other way.
 ObamaCare Repeal and Replace, Policy Brief and Resources, 2017. Accessed via https://www.nytimes.com/interactive/2017/02/16/us/politics/document-The-New-Obamacare-Replacement-Template.html
 Florida Agency for Health Care Administration. Florida Medicaid Presentation to the Senate Health and Human Services Committee, 2017, p. 2. Accessed via http://www.fdhc.state.fl.us/Medicaid/recent_presentations/index.shtml
 Rudowitz, Robin, Medicaid Financing: The Basics, 2016, p. 8, Kaiser Family Foundation. Accessed via: http://kff.org/report-section/medicaid-financing-the-basics-issue-brief/
 Florida Agency for Health Care Administration Presentation to the Senate Health and Human Services Committee, 2017, p. 2 & 9. Accessed via http://www.fdhc.state.fl.us/Medicaid/recent_presentations/index.shtml
 Florida Population and Components of Change, The Florida Legislature Office of Economic and Demographic Research, 2017. Accessed via: http://edr.state.fl.us/Content/conferences/population/ComponentsofChange.pdf
 Census: Florida growing older, more diverse, Associated Press, December 12, 2016, republished in Florida Politics, 2016. Accessed via: http://floridapolitics.com/archives/228659-census-florida-growing-older-diverse
 Demographic Estimating Conference, Executive Summary, February 13, 2017, The Florida Legislature Office of Economic and Demographic Research, 2017. Accessed via: http://edr.state.fl.us/content/conferences/population/demographicsummary.pdf
 Florida’s Population 2017- Volume 1, p. 3, The Florida Legislature Office of Economic and Demographic Research, 2017. Accessed via: http://edr.state.fl.us/Content/population-demographics /reports/econographicnews-2017v1.pdf
 Young, Katherine, Rudowitz, Robin, Rouhani, Saman, Garfield, Rachel, Medicaid Per Enrollee Spending: Variation Across States, Appendix Table 1, Kaiser Family Foundation, 2015. Accessed via: kff.org/medicaid/issue-brief/medicaid-per-enrollee-spending-variation-across-states/
 Park, Edwin, Commentary: Like a Block Grant Per Capita Caps Would Shift Costs to States and Place Beneficiaries at Risk, 2016. Accessed via: http://www.cbpp.org/healthhttp://www.cbpp.org/health/commentary-like-a-block-grant-medicaid-per-capita-cap-would-shift-costs-to-states-and-place/commentary-like-a-block-grant-medicaid-per-capita-cap-would-shift-costs-to-states-and-place
 Rudowitz, Robin, 5 Key Questions: Medicaid Block Grants and Per Capita Caps, p. 3, Kaiser Family Foundation, 2017. Accessed via: kff.org/medicaid/issue-brief/5-key-questions-medicaid-block-grants-per-capita-caps/
 Staletovich, Jenny, Two new virus-carrying tropical mosquitoes discovered in South Florida, The Miami Herald, 2017. Accessed via: http://www.miamiherald.com/news/local/environment/article125506669.html
 Florida Children’s Health Coverage Improves Since 2013, But 284,000 Children Remain Uninsured, Florida Policy Institute, 2016.
 Behavior Analysis Services Provider Information, Agency for Health Care Administration. Accessed via: www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/behavioral_health_coverage/bhfu/BA_Services.shtml
 Brooks, Tricia, Touscher, Joe, Artiga, Samantha, Stephens, Jessica, Gates, Alexandra, Modern Era Medicaid: Findings from a 50 -State Survey of Eligiblity, Enrollment, Renewal and Cost-Sharing Policies in Medicaid and CHIP as of January 2015, The Kaiser Commission on Medicaid and the Uninsured, Table 1, Adult Income Eligibility Limits as a Percent of the Federal Poverty Level, 2015. Accessed via: kff.org/health-reformkff.org/health-reform/report/modern-era-medicaid-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-as-of-january-2015//report/modern-era-medicaid-findings-from-a-50-state-survey-of-eligibility-enrollment-renewal-and-cost-sharing-policies-in-medicaid-and-chip-as-of-january-2015/
 Angeles, January, New Study Shows Link Between Medicaid Coverage of Prenatal and Infant Care and Better Long-Term Health Outcomes, 2014. Accessed via www.cbpp.org/blog/new-study-shows-link-between-medicaid-coverage-of-prenatal-and-infant-care-and-better-long-term
 Ng, Terence, Harrington, Charlene, Musumeci, MaryBeth, Reaves, Erica L., Medicaid Home and Community Based Services, 2012 Update, Table 14, 2015. Accessed via: kff.org/medicaid/kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/report/medicaid-home-and-community-based-services-programs-2012-data-update/
 Governor Rick Scott’s January 6, 2017 letter to Congress. Accessed via: http://www.flgov.com/wp-content/uploads/2017/01/smcl.pdf
American Rescue Plan Act Changes. The American Rescue Plan Act of 2021 extended PEUC and PUA benefits through the week ending September 6, 2021. It also increased the maximum duration of PEUC benefits ($300 a week) to 53 weeks and the maximum duration of PUA to 79 weeks. Although PEUC and PUA did not end until September 6, 2021, Florida withdrew from the Federal Pandemic Unemployment Compensation Program (FPUC) effective June 26, 2021. FPUC provided persons who were out of work due to COVID-19 with an additional $300 a week in unemployment insurance.
Reemployment Assistance weeks reverted to 12 effective January 1, 2022. DEO determines the maximum number of weeks available to RA claimants based on a statutory formula that looks at the average unemployment rate for the most recent third calendar year quarter (i.e., July, August, and September). Based on the downturn in unemployment, the maximum number of weeks for RA reverted to 12 effective January 1, 2022.
RA work-search and work registration requirements reinstated on May 30, 2021. Persons filing an application for RA benefits beginning March 15, 2020, are not required to complete work registration in Employ Florida through May 29, 2021. In addition, work search requirements for individuals requesting benefits for the weeks beginning March 15, 2020, were also reinstated on May 30, 2021.
Mobile app deployed. DEO has deployed a mobile app for RA applications.
DEO announces extended benefits. DEO announced implementation of Extended Benefits (EB).
Resources and guidance. For a list of resources and guidance from the United States Department of Labor on unemployment insurance and COVID-19, go here.
For DEO’s “Reemployment Assistance Frequently Asked Questions and Additional Resources,” updated 12/30/2020, go here.
For DEO’s latest claims data, go here.
DCF opens offices. DCF has reopened its brick-and-mortar storefronts, which were previously closed due to coronavirus.
DCF adds call center numbers. DCF has added a call center number for Monday through Friday, from 7 a.m. to 6 p.m. Call center numbers now include 850-300-4323, 866-762-2237, or TTY 1-800-955-8771.
Certification periods extended by 6 months only through August 2020. Certification periods for cash, food and medical assistance were extended by 6 months for individuals and families scheduled to recertify in April through August 2020. FNS’ approval of the SNAP extension for August is here. However, effective September 1, 2020, SNAP, TANF and Medicaid recertifications have been reinstated, although DCF says that no one will lose Medicaid due to recertification.
DCF allows phone interviews. Phone interviews are now being used for TANF cash and SNAP food assistance.
Mandatory work requirements suspended only through May 2021. Under a directive from Governor DeSantis to waive work requirements for safety net programs, DCF waived work requirements for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) through May 2021. To do this, DCF explains that it partnered with the Department of Economic Opportunity to apply “good cause” statewide for TANF and SNAP recipients who would otherwise be subject to participation in mandatory work requirements as a condition of receiving those benefits. Through May 2021, persons who were sanctioned in the past due to work requirements will be able to reapply and participate in SNAP or TANF again.
Work requirements were reinstated effective June 1, 2021.
Emergency allotments (EA) ended. DCF automatically supplemented SNAP allotments of current recipients up to the maximum for a household’s size for July 2021. However, EA was discontinued beginning August 1, 2021.
The SNAP benefits increase by 15 percent ended in October 2021. Floridians who participate in SNAP to put food on the table will receive a temporary 15 percent supplement to SNAP under COVID relief passed by Congress and extended by the American Rescue Plan Act through September 2021.
FNS permanently increases SNAP through revamp of the Thrifty Food Plan. Effective October 2021, FNS has mandated a permanent increase to SNAP through a revamp of the Thrifty Food Plan. DCF says that the increase amounts to about 6% for Floridians.
Time limits suspended. SNAP time limits are suspended during the COVID-19 public health emergency. No one in Florida should be barred from SNAP due to time limits, even if they exhausted their time limit in the past.
Florida granted waiver to allow families to purchase groceries online. DCF has been granted a federal waiver to permit the State of Florida to launch a pilot project statewide effective April 21, 2020, that allows families to purchase groceries online with their Electronic Benefit Transfer (EBT) card instead of going into stores.
No Medicaid terminations from March 2020 through the end of the federal public health emergency. The national public health emergency has existed since January 27, 2020 and has been renewed by the Secretary of the U.S. Department of Health & Human Services in 90-day increments since that time. The most recent renewal is effective January 16, 2022.
Redetermination/recertification times are reinstated. As of October 1, 2020 AHCA's website is alerting recipients that the Department of Children and Families is now mailing letters for case reviews to check if a household is still eligible for Medicaid and/or Medically Needy. AHCA is urging people receiving these letters to take steps now to re-apply. But note, Medicaid coverage will not end during the COVID-19 Public Health Emergency. In January 2021 DCF conducted one-year “automated renewals” for people whose sole income is social security and SSI and are enrolled in an SSI-related Medicaid program (e.g., MEDS/AD, Medically Needy and Medicare Savings Programs). People getting VA income were not included in the automated renewal.
Extended application time. Effective with applications filed in February 2020, the time for submitting documentation required to process an application is extended for 120 days from the date of the application and eligibility will still be effective the first day of the month the application was received. Effective July 1, 2021, this policy has been rescinded. Medicaid applications submitted on or after July 1, 2021 may be denied on the 30th day after application or the day after verification information is due. Applications filed prior to July 1, will be allowed 120 days to provide requested verification to establish Medicaid eligibility.
Exclusion of additional unemployment payments in determining eligibility. The $600/week of additional unemployment insurance payments under the CARES Act will not be counted as income in determining Medicaid eligibility. (However, these payments will be counted as income in determining marketplace subsidy calculations.)
Coverage of Medicaid services during the state of emergency
COVID-19 Vaccines for Medicaid Enrollees. In an executive order published March 16, 2021 Governor DeSantis revised the vaccine distribution plan, which applies to the general public including Medicaid enrollees, to lower the age requirement to 40 effective March 29, 2021 and then effective April 5, 2021 all Floridians are eligible to receive any COVID-19 vaccination approved by the Food and Drug Administration.
Medicaid enrollees eligible to receive the vaccine may visit myvaccine.fl.gov to find a location distributing the vaccine and to schedule an appointment.
On March 12, 2021, AHCA published instructions for Medicaid enrollees on how to obtain Medicaid transportation once they have scheduled an appointment for a vaccine. AHCA states: "Florida Medicaid will take you to get the COVID-19 vaccine at no cost. All you need to do is set up a time to get your vaccine. Next, let your Medicaid plan know you need a ride and they will take care of the rest. If you are not enrolled in a plan, call the Medicaid Helpline at 1-877-254-1055 to find out the name and phone number for a transportation service."
The state has also recently launched a new email system to help bring COVID-19 vaccines to homebound seniors. Seniors will be able to sign up to have the vaccine come to them by emailing a request to HomeboundVaccine@em.myflorida.com.
AHCA has posted Medicaid Alerts and FAQs providing more detail on Medicaid service changes in response to COVID-19. They address a wide range of topics including, but not limited to: telemedicine guidance for medical, behavioral health, and early intervention services providers; long-term care provider network flexibilities allowing more types of providers to deliver specified long term care services; and continuity of care for adult day care center enrollees during the time these centers are closed.
AHCA is loosening coverage restrictions for behavioral health services. Effective May 5, 2020, all prior authorization requirements for mental health or substance use disorder treatment are waived and service limitations (frequency and duration) are lifted. For behavioral analysis services, current authorizations will be extended through an "administrative approval process" which does not require providers to reassess beneficiaries currently getting services. Effective July 1, 2021 service limits will be reinstated for behavioral health services and effective July 15, 2021 Medicaid prior authorization requirements will be reinstated for behavioral health services.
Per a May 29, 2020 provider alert, during the state of emergency AHCA will be reimbursing providers for telemedicine well-child visits provided to children older than 24 months through age 20. Providers are directed to actively work to schedule follow-up in-person visits to administer immunizations and other physical components of the exam which cannot be accomplished through telemedicine.
Coverage of home and community-based waiver services (HCBS) - In response to the public emergency, Florida obtained approval from the federal government to make changes in HCBS waiver programs, including the Long Term Care and Developmental Disabilities programs. The changes are effective retroactively from January 27, 2020 to January 26, 2021. Details can be found here. They include, but are not limited to:
Note on COVID-19 testing, treatment, and vaccines for the uninsured. Florida has not opted to receive 100 percent federal Medicaid funding for COVID-19 testing of people without health insurance. Under the 2021 American Rescue Plan Act this option has been expanded to cover COVID-19 treatment and vaccines for the uninsured as well. Since the state has not taken up this option Floridians must look to an uneven patchwork of free testing, treatment, and vaccine resources scattered around the state. AHCA advises that uninsured people may receive free testing from their county health department or a federally qualified health center and that “many communities provide testing for free for individuals who do not have insurance. Please [click here] to find a test site in your area. Uninsured individuals should ask before the test whether testing is free of charge." There are no state agency instructions on where uninsured people can receive free treatment. However, more information on possible sources for free treatment is available here.
Residency proof no longer required at some vaccine sites, “paving the way for migrants.” - On April 29, 2021 Surgeon General Rivkees issued a new public health advisory specifying that COVID-19 vaccines are available to “a Florida resident” or someone “who is present in Florida for the purpose of providing goods or services for the benefits of residents and visitors of the State of Florida.” This new policy applies to all state-run and federally supported vaccination sites. It rescinds an advisory issued in January that had restricted vaccinations to people who could show proof of Florida residency
2021 unemployment compensation claimants can access free or reduced cost health insurance through the ACA marketplace. The Affordable Care Act (ACA) Marketplace was re-opened in February 2021 to give people who need health insurance a new “special enrollment" opportunity to get covered. The 2021 American Rescue Plan eliminated or vastly reduced premiums for many people with low or moderate incomes.
Starting July 1, 2021, people who received or have been approved for unemployment compensation for any week beginning in 2021 can access free or reduced cost comprehensive health insurance plans through the ACA marketplace. This benefit is available regardless of someone's current income. To get this benefit, people must enroll in the marketplace no later than August 15, 2021. For help with enrollment, contact Covering Florida at 877-813-9115.
School children in distance learning still eligible for free or reduced cost meals. Students in distance learning for 2020-21 can still receive school meals through the National School Lunch Program if they are eligible. The student or parent/guardian may pick up meals at the school but should contact their school for more information.
For a list of current child nutrition program waivers for Florida from USDA, go here.
Congress allows increased fruit and vegetable benefits. At present, WIC provides $9 for children and $11 for women monthly for fruits and vegetables. The American Rescue Plan Act makes funding available for a four-month increase in the benefit of up to $35 monthly, if a state chooses to do so.
DOH attains waiver allowing remote issuance: Department of Health (DOH) obtained a waiver of the requirement that participants pick up their EBT cards in person at recertification or during nutritional education appointments.
WIC participants allowed to substitute certain food. Under a waiver from USDA, WIC participants in Florida are allowed to substitute milk of any available fat content and whole wheat or whole grain bread in package sizes up to 24 oz. when 16 oz. packages are unavailable.
USDA waived physical presence requirements: Although the scope and logistics are unclear at this time, USDA has given DOH permission to waive the requirement that persons be physically present at each certification or recertification determination in order to determine eligibility under the program through May 31, 2020.
USDA extends certification periods through May 31, 2020, for some participants.
For a list of current WIC waivers for Florida from USDA, go here.
HHS provides guidance. HHS has issued guidance on the flexibilities in TANF to respond to COVID-19.