What is Medicaid Share of Cost - explain with example

Can you please let me know how to check eligibility on share of cost patients?

A Medically Needy recipient is an individual who would qualify for Medicaid, except that the individual’s income or resources exceed Medicaid's income or resource limits. A Medically Needy recipient becomes eligible on the day that the recipient incurs allowable medical expenses that equal or exceed the amount by which his income exceeds the Medicaid income standard (share of cost).

Recipients with a Share of Cost should be treated as private pay patients until they meet the Share of Cost amount. They should be informed that they will be responsible for the charges if they do not incur enough medical expenses to meet the Share of Cost. Information on the Share of Cost amount can be provided by the recipient or the Department of Children and Families (DCF).


Is DCF the only agency that determines share of cost?

Yes. Enrollment in the Medically Needy program only happens with DCF determinations. There is no similar program for SSI determinations through the Social Security Administration. Their applicants are either eligible for full coverage or not at all.

What is “Share of Cost” Medicaid?

When eligibility for Medicaid is determined, some people will meet all the technical requirements except that their income or the value of their assets (resources) is too high. These people can be enrolled in the Medically Needy program. The difference between the person’s income and the qualifying limit for full Medicaid is their “Share of Cost” (SOC).

For example, if the income limit for a person to get full Medicaid is $350/month and the person makes $500/month, this person’s SOC would be $150. Any month that this person’s medical expenses are more than $150, the person will get Medicaid coverage. Coverage will begin on the day the SOC is met and continues to the end of the month. Persons enrolled in Medically Needy will not be listed when you try to verify eligibility unless medical bills or other proof of medical expenses have been sent to the appropriate DCF office. DCF uses the bills to establish the date when the person is Medicaid eligible. Please contact your Area Medicaid Office for information on sending bills to DCF for tracking. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at:
http://mymedicaid-florida.com/.

Do we bill for share cost monthly or wait until monthly bills are submitted?
You can bill at any time after the person’s eligibility is established for the month

How do we check how much a recipient has already met or needs to meet before being considered eligible for full Medicaid?
If the recipient cannot give you the information on his/her Share of Cost, you will need to get the information from DCF. You can use the DCF Provider View link from the secure area of http://mymedicaid-florida.com . You can also contact the DCF call center at: 1-866-762-2237 or send a written request at this web site: https://www.dcf.state.fl.us/contact/contact_email.shtml?recv=ACCESS.