Medicaid SFU and Budgeting: MFAM and MSSI Module 5 Study Notes

Terminology Crosswalk and Management Portal Overview

• Transition Context: The Florida ACCESS Management Portal launched in Summer 2025. It serves as a workload management component for tracking electronic and paper applications throughout the eligibility process.

• System Replacement: This portal replaces the legacy ACCESS Management System (AMS) and several components of the eligibility system known as "FLORIDA."

• Legacy Terminology Comparison:

  • ACCESS Number: Now referred to as Work Item Number / Application Number.

  • ACCESS Summary: Now referred to as Application Summary.

  • Application Number: Now referred to as Client Registration #.

  • CLRC: Now referred to as Case Notes.

  • CRAD: Now referred to as Client Registration.

  • Document Imaging / ADI / DVS: Now referred to as Document Management.

  • FLORIDA ID (FLA Z#): Now referred to as RACF ID.

  • Interview Template: Now referred to as New Application Notes.

• MyACCESS Modernization: Users are advised that transmittals may still reference outdated terminology. For full FLORIDA replacement, users must use the "Management Portal" as appropriate based on current system releases.

Objective 1: Determine a Payee or Authorized Representative for Medicaid Benefits

• Medicaid (MFAM and MSSI) Payee: Individuals may designate a non-assistance group or assistance group member to apply or receive benefits on behalf of the group. No specific requirements govern who may be designated.

• Authorized Representative:

  • Desginants include the applicant, spouse, legal guardian, Power of Attorney (POA), or a responsible member of the assistance group.

  • Preferred designation method: Signed CF-ES 2505 (Appointment of a Designated Representative) form. Written requests satisfying all requirements are also accepted.

  • Legal Documents: Signed statements are not required for legal guardians or POAs if verifiable legal documents are already on file.

• Case Maintenance Screens:

  • AGCD (Assistance Group Composition Display): Found at the beginning of eligibility determination via the AABC/EDBC driver.

  • AGCC (SFU Composition Change): Shows participation status and option types for each member. Each individual in MFAM has a specific AGCC screen.

  • AGPY (Assistance Group Names): Used to designate a payee for each AG using the "Short List" number. This screen captures "WISH TO APPLY" (Y/N) decisions and the application date.

  • AGBI (Assistance Group Benefit Information): Links to detail screens for alternate addresses, protective payees, and authorized representatives. Requires an Originating County code.

  • AGAR (Assignment of Authorized Representative): Accessed via AGBI to assign the representative.

Objective 2: Identify Medicaid Coverage Groups (MFAM and MSSI)

Family-Related Medicaid (MFAM) Categories

1. MA R: Parents and other caretaker relatives (Household income $\le 19\% \text{ of FPL}$).

2. MMFP: Family Planning Medicaid (Women ages 14–55; income $\le 185\% \text{ of FPL}$).

3. MM P: Pregnant woman (Income $\le 185\% \text{ of FPL}$).

4. MU: Presumptively Eligible Pregnant Woman (PEPW) (Outpatient prenatal only; based on verbal statement).

5. MM T: Pregnant woman protected Medicaid (Maintains coverage through 12-month postpartum despite income increases).

6. MM I: Infants under age 1 (Income $\le 200\% \text{ of FPL}$).

7. MN: Presumptively Eligible Newborn (PEN) (Born to a Medicaid-eligible mother).

8. MM C: Children ages 1 to 19 (Income $\le 133\% \text{ of FPL}$).

9. MO Y: Children ages 19 to 21 (Income $\le 19\% \text{ of FPL}$).

10. ME C: Extended Medicaid (Due to alimony/spousal support).

11. ME I: Transitional Medicaid (Due to earned income; up to 12 months).

12. MA I: Former Foster Care Children (Under age 26; those who aged out of foster care at 18).

13. ML A: Emergency Medicaid for Noncitizens (Qualifying emergency condition only).

Ex Parte Determinations

• Definition: An assessment of whether an individual no longer eligible under one coverage group qualifies for another before benefits are terminated.

• Triggers:

  • Income increase.

  • Child turning 18 or 19.

  • Claiming disability (evaluate under MSSI while MAGI Medicaid continues pending decision).

  • Expiration of transitional periods (ME I) or PEN coverage.

  • Cancellation of SSI.

SSI-Related Medicaid (MSSI) Categories

• MMS (MEDS-AD): Full Medicaid for aged ($65+$) or disabled individuals with income $\le 88\% \text{ of FPL}$ and assets $\le$ $5,000 (individual) or $6,000 (couple).

• Medicare Buy-In Programs (Medicare Savings Programs):

  • QMB: Pays Part A/B premiums, deductibles, and co-insurance. No retroactive coverage.

  • SLMB: Pays Part B premium only.

  • QI1: Pays Part B premium only.

  • QDWI: Pays Part A premium for disabled working individuals.

• Home and Community Based Services (HCBS): Waiver programs (iBudget, SMMC LTC, WPwD) meant to prevent institutionalization. Income/Asset limits usually follow ICP/MEDS-AD standards.

Objective 3: Determine a Standard Filing Unit (SFU) for MFAM

• Definitions:

  • Standard Filing Unit (SFU): The group of individuals whose needs, income, or assets are considered for eligibility.

  • Assistance Group (AG): The individual(s) actually receiving benefits. In MFAM, the AG is the individual being tested.

• MFAM Rule 1 (Tax Filer): The SFU includes the tax filer, the spouse living in the home (or filing jointly), all claimed tax dependents (regardless of age/residence), and any unborn children.

• MFAM Rule 2 (Tax Dependent): The SFU includes the tax dependent, the claiming tax filer, the filer's other dependents, the dependent's spouse (if in the home), and unborn children.

  • Rule 2 Exceptions: Use Rule 3 (Non-filer) if the dependent is not a child or spouse of the filer, or children living with both parents who don't file jointly, or children claimed by a non-custodial parent.

• MFAM Rule 3 (Non-Filer):

  • Rule 3A (Adults): Individual, spouse, and children (biological/step/adopted) under 19, or 19-20 if full-time students.

  • Rule 3B (Children under 21): Child, parents (biological/step/adopted) in home, and siblings (biological/step/adopted) under 19, or 19-20 if full-time students.

• Child Participation (XC): If an AG is ineligible due to a child's income, the child with income may be marked as an "Excluded Child" (XC) to reduce the Share of Cost for others in the MFAM Medically Needy group.

Objective 4: Income and Expenses of Ineligible or Disqualified Members

• Noncitizen Status/SSN Requirement:

  • MFAM: Income of the ineligible member is counted. Needs are counted in the SFU (CA/CC status) but not in the AG.

  • MSSI: Ineligible adult is removed. Assets counted in full; income is deemed (DS status).

• Child Support Non-compliance:

  • MFAM: Income of the ineligible member is counted (CA status).

  • MSSI: Ineligible adult removed; assets counted in full; income is deemed.

• Drug Felons/Fleeing Felons: Use normal SFU rules unless income is otherwise excluded.

• Third Party Liability (TPL):

  • MFAM: Count income; needs in SFU (CA) but not in AG.

  • MSSI: Adult removed (DS status).

Objective 5 & 10: Determine SFU and Deeming for SSI Related Medicaid

• SFU Size: Always 1 or 2.

• SFU of 1: Single individual, or disabled child, or married individual where the spouse is not aged/blind/disabled and has income < \frac{1}{2} \text{ FBR}.

• SFU of 2: Spouses both aged/blind/disabled, or when an ineligible spouse has income $\ge \frac{1}{2} \text{ FBR}$.

• FBR (Federal Benefit Rate): The base rate for SSI. $\frac{1}{2} \text{ FBR} =$ $497.

• Allocated Dependent: An ineligible child (under 18 or under 21 and a student) who lives with the couple. An allowance is made in the deeming budget to lower the deemed income amount.

• Parent to Child Deeming Formula:

  1. Determine total parental income.

  2. Subtract unmet need allocation for ineligible children ($\text{Couple FBR} - \text{Individual FBR}$).

  3. Subtract standard disregards ($20 standard and 65 + \frac{1}{2} earned$).

  4. Subtract parent allocation (FBR for 1 or 2).

  5. The remainder is deemed unearned income to the child.

Objective 6: MFAM Budgeting Formula

• Step 1: Countsable Gross Earned + Countable Gross Unearned + Deemed Sponsor Income.

• Step 2 (MAGI Calculation): $\text{Total Reported Income} - \text{Allowable IRS Form 1040 Schedule 1 (Line 22) Tax Deductions} = \text{MAGI}$.

• Step 3: Compare MAGI to Income Standard.

• Step 4 (Standard Disregard): Subtract the Standard Disregard (not applicable to children aged 6 to 18).

• Step 5 (MAGI Disregard): Subtract $5\% \text{ of FPL}$ from the result in Step 4.

• Step 6 (Medically Needy): If still ineligible, subtract the Medically Needy Income Level (MNIL) from the MAGI to determine the Share of Cost (SOC).

• Step 7: Subtract medical insurance premiums and recurring medical expenses from the SOC.

Objective 8: Date of Eligibility

• General Rule: The 1st day of the month the application is received (if eligible that month) or the 1st day of the month ongoing eligibility begins.

• Medically Needy Exception: Benefits start any day of the month once the Share of Cost is met.

• Emergency Medicaid Exception: Coverage dates must exactly match the start and end dates of the verified medical emergency.

• Review Period: Medicaid typically carries a 12-month review period beginning with the month of authorization.

Objective 9: MSSI Medicaid Budgets

• Standard Disregard: $20 \text{ per month}$ applied to total income. Applied to unearned income first, then any remainder to earned income.

• Earned Income Disregard: $65 + \frac{1}{2} \text{ of the remaining balance}$.

• Budget Steps:

  1. $\text{Unearned Income} - 20 \text{ (disregard)} = \text{Countable Unearned Income}$

  2. $\text{Gross Earned Income} - 65 - \text{Remaining Balance} \div 2 = \text{Countable Earned Income}$

  3. $\text{Total Countable Income} = \text{Step 1 Result} + \text{Step 2 Result}$

Objective 11: Medically Needy Share of Cost and Bill Tracking

• Share of Cost (SOC): The amount countable net income exceeds the MNIL.

• Estimated vs. Actual SOC: The system can pass a case with an estimated SOC based on customer statements (Code 054), but income must be verified (to Code 050) before bills are tracked.

• Bill Tracking Priority Order (on the same day):

  1. Medicare or health insurance premiums/costs.

  2. Medical bills belonging to individuals not entitled to Medicaid.

  3. Paid medical bills.

  4. Medicaid payable medical expenses.

• Allowable Bills: Must be recognized medical services (doctors, hospitals, insulin, service animals). Unpaid bills < 1 year old are accepted via statement; > 1 year old require proof of debt to provider.

• Third Party Liability (TPL): Insurance payments must be subtracted. Exception: Public programs (County Health Unit, CMS) where the full cost can be used for tracking even if the city/state pays.

• Global Bills: Prenatal/surgery bills covering a package can be used or prorated over the duration of the pregnancy/condition.

• Referrals: Individuals failing full Medicaid but entering Medically Needy are referred to Florida Healthy Kids (CHIP) for children or the Federally Facilitated Marketplace (FFM) for adults via system codes 512, 514, or 515.

Questions & Discussion

• Q: Can a 19-year-old be both a tax filer and a tax dependent?

  • A: Yes. In this case, test them as a tax dependent under Rule 2. On the FLORIDA AIHH screen, the ES must indicate the individual is NOT filing taxes because the system does not recognize a tax dependent of another tax dependent.

• Q: How is the father of an unborn child treated in MFAM?

  • A: If married to the pregnant woman, he is excluded from the AG but his income is counted in the SFU (CA status). If NOT married, he is excluded from both the AG and the SFU (XA status) and his income is not considered if the unborn is the only child.

• Q: What happens if a child under age 19 becomes ineligible for Medicaid?

  • A: They may remain on Medicaid for up to twelve months after their last review under continuous eligibility provisions.

• Q: Is medical marijuana an allowable medical expense?

  • A: No. Per transmittal P-18-08-0016, the cost of medical marijuana and associated expenses are not allowable for either Food Assistance or Medically Needy tracking.