Medicaid patients – who are eligible for Managed care plan






Enrollment in Medicaid Programs

The State of Florida (State) has the sole authority for determining eligibility for Medicaid and whether Medicaid Recipients are mandated to enroll in, may enroll in or may not enroll in Medicaid Reform. The Agency for Health Care Administration (Agency) or its Agent reviews the Florida Medicaid Management Information System (FMMIS) file daily and sends written notification and information to all potential Members. A potential Member has (30) calendar days to select a health plan. If the Member does not choose a plan, the Agency or its Agent will auto-assign the Member to a health plan using a pre-established algorithm.

The following groups of Florida Medicaid Recipients are authorized to enroll in a managed care plan:

Low Income Families and Children

Sixth Omnibus Budget Reconciliation Act (SOBRA) Children

Supplemental Security Income (SSI) Medicaid Only

SSI Medicare, Part B only

SSI Medicare, Parts A and B

Medicaid Recipients who are residents in Assisted Living Facilities and are not enrolled in an ALF waiver program

Refugees

The Meds AD population

Individuals with Medicare coverage (e.g., dual eligible individuals) who are not enrolled in a Medicare Advantage Plan

Title XXI MediKids are eligible for Enrollment in the Health Plan in accordance with Section 409.8132, F.S. Except as otherwise specified the Health Plan contract,
Title XXI MediKids eligible participants are entitled to the same conditions and services as currently eligible Title XIX Medicaid Recipients

Women enrolled in the Health Plan who change eligibility categories to the SOBRA eligibility category due to pregnancy remain eligible for Enrollment in the Health Plan

Only Medicaid Recipients who are included in the eligible population and living in counties with authorized Health Plans are eligible to enroll and receive services from the Health Plan. The Agency or its Agent shall be responsible for Enrollment, including Enrollment into a Health Plan, Disenrollment, and outreach and education activities.

The following Medicaid recipients are not eligible to enroll in a Medicaid managed care plan:

Recipients who reside in an Intermediate Care Facility for the Developmentally Disabled (ICF/DD); nursing facility, state mental hospital

Recipients who are under the age of (21) and are enrolled in Children’s Medical Services or attend a prescribed pediatric extended care center

Recipients under (18) who are in a Statewide Inpatient Psychiatric Program (SIPP)

Recipients who receive hospice services

Recipients who are enrolled in a Medicare or private HMO or other healthcare insurance such as TRICARE (formerly known as CHAMPUS)

Recipients who are eligible for limited Medicaid under such programs as the Family Planning waiver; Medically Needy or Qualified Medicare Beneficiary (QMB)