Medicaid Costs and Coverage in Florida

“How much is Medicaid in Florida?” is a simple question with a complicated answer. To accurately answer, “How much does Medicaid cost?” one must know and account for numerous details of a beneficiary’s household size, income and family structure. Medicaid cost estimates vary widely and may change over time with changes in a household’s medical needs and expenses. Typically, the best way to understand and anticipate Medicaid costs is to understand what services are covered by Medicaid, in part or in full, which services are not covered at all and what other factors can affect a household’s Medicaid expenses. For this, it is helpful to begin by looking at the types of Medicaid insurance, as which type an applicant has qualified for and enrolled in plays an important role in what services he or she can expect to access and at what level of cost. Continue reading below for more information on Medicaid costs and coverage in Florida.

What services are covered by Medicaid in Florida?

Medicaid coverage in Florida is administered by the state Agency for Health Care Administration. In 2014, the Agency adopted a Statewide Medicaid Managed Care (SMMC) program. Under SMMC, when a new recipient completes the Medicaid enrollment process, a choice counselor assists them in selecting and registering with a nationally accredited managed care plan. This managed care plan then delivers all services are covered by Medicaid with the exception of long-term care related benefits. Recipients are issued gold Medicaid cards, which they present whenever they receive services. What services a managed care plan will make available to a recipient varies by the type of Medicaid insurance a recipient has, his or her age and whether or not he or she has a diagnosed disability or health condition. The availability of services under Medicaid coverage may also be influenced by determinations of medical necessity.

Many services are covered by Medicaid, particularly those deemed primary and preventative care. Medicaid recipients have access to standard medical care, behavioral health care, dental care, prescription medications and, when applicable, specialist services. All types of Medicaid insurance provide primary and preventative care informed by recommendations from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention (CDC). In keeping with these recommendations, services covered by Medicaid at well-patient visits include:

  • Taking a patient’s family and medical histories.

  • Physical exams.

  • Blood work and urine tests.

  • Vaccines.

  • Behavioral health screenings.

At primary health care visits for children, Medicaid coverage pays for additional screenings and health and safety education. At primary health care visits for adults, all types of Medicaid insurance cover blood pressure and cholesterol screenings, hearing exams, alcohol, tobacco and substance use consultations and patient education on heart health, nutrition and physical activity. Services covered by Medicaid during routine visits for female Medicaid recipients include those related to women’s health issues, family planning, pregnancy and maternity care. Most types of Medicaid insurance offer extensive care options for recipients with disabilities or qualifying medical conditions, to include:

  • Orthotic and Prosthetic Devices.

  • Physical Rehabilitation services.

  • Durable Medical Equipment.

  • Hearing Aids.

  • Physical, Occupational and Speech Therapies.

Where it is deemed medically necessary or appropriate, Medicaid coveragewill cover the costs of laboratory testing, x-rays and other radiology services, ambulatory surgery and outpatient hospital care. Hospital and emergency room visits and ambulance services may be fully or partially covered, as well. Additional services covered by Medicaid for recipients who meet the eligibility requirements may include home health care, audiology services, dialysis and hospice placement.

Behavioral health care is also covered by Medicaid. Services covered by Medicaid insurance for recipients with behavioral health needs and conditions include case management services, psychological testing, Autism Spectrum Disorder Services, detoxification services and both outpatient and intensive outpatient services. When necessary Medicaid benefits may pay some or all of the costs associated with psychiatric hospitalization and observation periods.

In the event that a Medicaid insurance recipient is also enrolled in Medicare, Medicaid funds may be available to pay for the individual’s Medicare deductible and/or some of the recipient’s co-pay and co-insurance costs under Medicare. Medicaid coverage may also partially cover medical costs not eligible for coverage under Medicare and may provide some assistance with paying Medicare coverage premiums.

For more details on Medicaid’s costs and coverage, download our comprehensive guide.

What does Medicaid not cover in Florida?

Like other questions about Medicaid, what services are not covered by Medicaid in Florida is largely dependent on what type of Medicaid insurance a recipient household is enrolled in. It is also strongly influenced by an individual recipient’s personal health, as many services and procedures may be covered under Medicaid but will only be authorized for patients who have demonstrated medical need. For example, Medicaid coverage will pay for screenings for patients deemed to be at high risk for a disease or condition, and these services are not available to other recipients. These include screenings for Tuberculosis, Hepatitis B and C, HIV and Colorectal Cancer. Recipients identified as having medical need may be eligible for behavioral health related residential treatment, but only after all other options have been exhausted. Some Medicaid insurance recipients, such as children, may qualify for services under Medicaid-related programs like CHIP, which would not otherwise be available to most Medicaid recipients.

Primarily, however, the question of what services are covered by Medicaid most often comes down to who renders a service to a patient rather than what the service is. Medicaid does not cover medical services delivered to recipients by providers who are not enrolled in or approved by the recipient’s managed care plan. At the time of enrollment, all recipients receive a list of the providers in their plan’s network. Although it is sometimes possible to have Medicaid insurance cover the costs of testing, referrals or prescriptions provided by out-of-network providers, these instances must be approved in advance and usually only under extenuating circumstances. Any other services delivered by unauthorized providers will not be covered. Patients will be required to pay the full costs of non-approved services out of pocket.

How much does Medicaid cost In Florida?

The cost of Medicaid in Florida varies from household to household. Medicaid cost estimates must take into account a variety of factors, including how a household qualified for, household income and the types of income, as well as frequency and number of services a household accesses through its managed care plan. How much Medicaid costs a household generally rises with its household income, and households with higher incomes are expected to shoulder more cost-sharing and co-pay expenses than lower income households. Similarly, Medicaid costs can be projected to be lower for households accessing routine and preventative care only than for those accessing more extensive or specialty services.

Download our comprehensive guide for more details on the costs of Medicaid and the services that these benefits cover.