House Memorial (HM) 7033, which urges Congress to establish Medicaid block grants, includes multiple misstatements about the Medicaid program. Floridians deserve a thoughtful, fact-based Medicaid policy discussion before the Legislature acts to fundamentally change a program that provides a lifeline for 4 million Floridians.
The Florida House just passed HM 7033, entitled “A memorial to the Congress of the United States, urging Congress to establish Medicaid block grants.”
In lawmaker language, memorials are used to voice concerns and opinions to the U.S. Congress. But for the rest of us, it’s a word connected to a funeral. That seems to be an appropriate description of the motivation behind this effort, a desire to end Medicaid as we know it. The program is a lifeline for 4 million Florida children, pregnant women, persons with disabilities and seniors.
The memorial recites multiple misleading and inaccurate assertions about Medicaid. Let’s unpack these statements and debunk the myths:
Memorial Assertion: The Medicaid program costs $25.8 billion – 31 percent of the state budget.
Reality: While this statement is true, it’s misleading. In fact, $15.7 billion, 61 percent of Florida’s total Medicaid budget, is funded through federal dollars. It is the largest source of federal funding for the state.
The reality is that the state’s Medicaid budget will be severely squeezed under the pending U.S House health plan proposal to cap federal Medicaid funding. Projections are that under this plan, $116 billion of new costs will be shifted to the states over a 10-year period. (This is in addition to a shift of $253 billion due to cuts in Medicaid expansion states). This growing dent in Florida’s federal Medicaid share will box in legislators to the following difficult policy choices: find state revenues to fill in the hole, or more likely, make cuts to eligibility, services or provider reimbursements.
Memorial Assertion: Nationally, Medicaid enrollment accounted for the largest increase of enrollment under the ACA.
Reality: The assertion is true on a national level, but not true for Florida.
The national increase was due to 31 states and D.C. expanding their Medicaid programs to provide coverage to millions of previously uninsured. The 19 states that failed to expand Medicaid, including Florida, have uninsured rates significantly exceeding the national average. (13.3 percent in Florida vs. 9.4 percent nationally.)
But notably, looking at the other side of the Affordable Care Act (ACA) equation, the largest increase nationally in private insurance enrollment through the federal marketplace has taken place in Florida with 1.8 million enrollees.
Memorial Assertion: Medicaid is a stigmatizing welfare program.
Reality: This is an undeserved stereotype. How can it be a “disgrace” (the definition of stigma) to be covered by Medicaid? Medicaid covers 4 million Floridians and over 70 million individuals throughout the country. It’s highly likely that your family, friends or neighbors – mainly children, persons with disabilities and seniors – depend on Medicaid for quality health care and survival. These are:
Memorial Assertion: Medicaid achieves poor quality outcomes.
Reality: Research shows that people with Medicaid can see a doctor when they need one and get care more easily than uninsured individuals, and that their access to care is on par with those covered by employer-sponsored insurance. Across the country, most Medicaid enrollees report being satisfied with their health care and they have health outcomes comparable to, or better than, the privately insured. Florida’s own Medicaid agency – the Agency for Health Care Administration – recently released a “snapshot” of Medicaid managed care asserting that Medicaid quality of care is “reaching record levels and consumer satisfaction is high.”
Memorial Assertion: Medicaid is a federally-prescribed complex system of eligibility, financing and service delivery models, subject to extensive, complicated, prescriptive and outdated federal laws and regulations.
Reality: Medicaid is a partnership between the states and federal government. Although federal law prescribes broad parameters for administration of the program, states have multiple options for tailoring their programs to meet their residents’ needs and state budgets. (That is why there are 50 different Medicaid programs.) States have options around the delivery of services (such as managed care models), provider reimbursements, eligibility groups and services covered. During its 50-year history, Medicaid laws have been repeatedly amended and updated to accommodate states’ needs and reflect changes in the health care landscape.
Memorial Assertion: Opportunities for innovation and modernization are limited.
Reality: States already have substantial flexibility to design, innovate and modernize their Medicaid programs, including how care is paid for and delivered. For example, new options are available under the ACA that allow states to establish “health homes,” providing intensive care coordination to beneficiaries who make frequent visits to the emergency room.
Additionally, for over a decade, pursuant to the direction and oversight of the Legislature, Florida has received broad federal authorization under a demonstration waiver to implement its statewide Medicaid managed care program. Through this program, the state has been a leader in innovative policy choices that have subsequently been adopted by the federal government in national Medicaid managed care standards.
Memorial Assertion: The current financing model encourages states to shift state spending into the Medicaid program, so states gain little benefit from efficiency and bear little risk for wasteful expenditures.
Reality: Which part of the Florida Medicaid program does the Legislature consider wasteful? Dollars used to reduce the number of uninsured children? To provide pre-natal care to pregnant women? To provide in-home services to persons with disabilities so they can stay out of nursing homes?
The truth is that Florida leaders recognize the extraordinary benefits that Medicaid provides to Floridians and the state budget. Case in point: a recent legislative “revenue maximization” report describes multiple ways in which state dollars can be leveraged to draw down federal Medicaid funding for improving Florida’s mental health service delivery system.
Medicaid already has a much lower rate of growth and lower administrative costs compared to the private health insurance sector. Employer based insurance spending is 28 percent higher and beneficiary out of pocket costs are more than three times higher. Florida’s per capita enrollee spending is nearly the lowest in the country. Florida has an extremely lean Medicaid program and the Legislature will be hard pressed to find any fat.
Memorial Assertion: A reasonable, predictable funding mechanism that does not incentivize state spending increases will force states to make more rational, efficient spending choices, naturally reducing the rate of cost growth.
Reality: Converting from the current Medicaid financing scheme with open ended federal funding to block grants or per capita caps will trigger substantially more unpredictability. Capped funding will hamstring state leaders trying to meeting the challenges of a growing elderly population and unanticipated health care costs arising from epidemics, such as Zika, the opioid crisis, natural disasters or new life-saving health innovations. Historically, federal block grants have not kept pace with population growth, inflation or market rate increases. The only thing predictable with capped funding is a steady decline year after year in federal funding, likely resulting in cuts to the program. These decisions will have life-altering consequences for the most vulnerable Floridians.
Memorial Assertion: Granting states complete flexibility will help states transform the Medicaid program.
Reality: “Complete flexibility” is code for giving states license to gut the guarantees of Medicaid coverage existing under current law. These guarantees include a benefit package tailored to meet the unique needs of children, limitations on what families can be charged for services, and required coverage of certain mandatory services, such as physician visits and hospitalizations.
Rather than rehashing baseless disparagements of the Medicaid program, Florida leaders need to engage in an evidence-based, thoughtful policy debate before choosing to go down a dangerous Medicaid “death-spiral” path.
 Park, Edwin, Aron-Dine, Aviva, Broaddus, Matt, House Republican Health Plan Shifts $370 Billion in Medicaid Costs to States, Center on Budget and Policy Priorities, 2017. Accessed via: http://www.cbpp.org/research/health/house-republican-health-plan-shifts-370-billion-in-medicaid-costs-to-states
 Florida Medicaid, Florida Agency for Health Care Administration 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
 Office of Economic and Demographic Research, Executive Summary for Caseloads and Expenditures, 2016, p. 1. Accessed via: http://edr.state.fl.us/Content/conferences/medicaid/index.cfm
 Cooper, Elizabeth, Debunking Medicaid Critics: Facts on Health Care Quality and Access, 2015. Accessed via: http://familiesusa.org/blog/2015/05/debunking-medicaid-critics-facts-health-care-quality-and-access
 Paradise, Julia, Garfield Rachel, What is Medicaid’s Impact on Access to Health Care, Health Outcomes and Quality of Care? Setting the Record Straight, The Kaiser Commission on Medicaid and the Uninsured, 2013, pp. 4,6,8,10. Accessed via: http://kff.org/report-section/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence-issue-brief/
 A Snapshot of the Florida Statewide Medicaid Managed Care Program, Florida Agency for Health Care Administration. Accessed via: https://ahca.myflorida.com/…/SMMC_Quality_and_Performance_Snapshot. pdf
 Solomon, Judy, Caps On Federal Medicaid Funding Would Give States Flexibility to Cut, Stymie Innovation, 2017, pp. 1-2. Accessed via: http://www.cbpp.org/research/health/caps-on-federal-medicaid-funding-would-give-states-flexibility-to-cut-stymie
 Supra, p. 2; Health Homes, Medicaid.gov, Keeping America Healthy. Accessed via: https://www.medicaid.gov/medicaid/ltss/health-homes/index.html
 Behavioral Health Services Revenue Maximization Plan, Report to the Florida Legislature, December 31, 2016, pp. 3-4
 Clemons-Cope, Holahan, John, Garfield, Rachel, Medicaid Spending Growth Compared to Other Payers: A Look at the Evidence, 2016. Accessed via: http://kff.org/report-section/medicaid-spending-growth-compared-to-other-payers-issue-brief/
 Coughlin, T.A., Long, S.K., Clemons-Cope, L., Resnick, D. What Difference Does Medicaid Make? Assessing Cost-Effectiveness, Access and Financial Protection Under Medicaid for Low Income Adults, 2013, p. 7. Accessed via: http://www.urban.org/research/publication/what-difference-does-medicaid-make-assessing-cost-effectiveness-access-and-financial-protection-under-medicaid-low-income-adults
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.