Florida and the ACA’s Medicaid expansion

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Nearly 400,000 in coverage gap

Given Florida’s large overall population, it also has a large Medicaid population — more than 4.2 million as of May 2018. However, a family’s income must be quite low to qualify for the program. And most adults who don’t have children aren’t eligible for Medicaid in Florida, because the state hasn’t accepted federal funding to expand coverage — despite the fact that 68 percent of Florida residents support Medicaid expansion.

The Affordable Care Act (ACA) doesn’t provide subsidies for people with income below the poverty level, because the law called for them to have Medicaid instead. But in 19 states that have refused Medicaid expansion — including Florida — people who aren’t eligible for Medicaid and whose income is too low for exchange subsidies are in what’s called the coverage gap (note that there’s no coverage gap in Wisconsin, Medicaid will be expanded in Virginia as of January 2019, and Maine voters approved Medicaid expansion with a ballot initiative, but implementation has been held up by the governor). Unfortunately, people in the coverage gap have little in the way of affordable access to healthcare. In Florida, 384,000 people are in the coverage gap; only Texas has more people in the coverage gap.

Republicans control Florida’s House and Senate, and Republican Governor Rick Scott has been outspoken in his opposition to the ACA, including Medicaid expansion. Democrats in the Florida legislature have been pushing for Medicaid expansion for years, but have consistently been blocked by Republicans. The issue could be addressed again in the 2019 legislative session, and Florida will have a new governor in 2019, as Scott is term-limited and running for a US Senate seat instead.

Do you qualify for Florida Medicaid?

To qualify for federal funding, state Medicaid programs are required to cover certain populations, such as low-income children and pregnant women. States can also choose to cover optional coverage groups, like low-income adults without dependents.

Each state sets its own income limits for qualification, based on minimum levels set by the federal government. Florida has set below-average limits for the mandatory coverage groups, and since the state has not accepted federal funding to expand Medicaid, the eligibility rules have not changed with the implementation of the ACA. Able-bodied, non-elderly adults who don’t have dependents are not eligible for Medicaid in Florida, regardless of how low their income is.

Florida’s eligibility standards as of April 2018 are:

  • Children up to 1 year old: 206 percent of the federal poverty level (FPL)
  • Children ages 1-5: 140 percent of FPL
  • Children ages 6-18: 133 percent of FPL
  • Pregnant women: 191 percent of FPL
  • Young adults, ages 19 and 20: 29 percent of FPL
  • Adults with dependent children: 29 percent of FPL

People who qualify for Supplemental Security Income (SSI) automatically qualify for Medicaid in Florida. See more information in the SSI-Related Programs Financial Eligibility Standards.

How do you sign up for Medicaid?

If you’re eligible for Medicaid, you can enroll at Healthcare.gov.

You can also apply online at ACCESS Florida, or fill out a paper form. Use this application for low-income children, pregnant women, families, and aged or disabled individuals who are not currently receiving Supplemental Security Income (SSI).

Use this application to apply for food or cash assistance in addition to Medicaid. You should also use this form if you currently receive SSI or if you are applying for home based and community services, hospice care, or nursing home care.

Paper applications can be submitted by mail, fax or in person to a local service center.

For help with the application process, call 1-866-762-2237.

Florida won temporary LIP funding from the Obama Administration, but Trump Administration increased & extended it

According to a Kaiser Family Foundation analysis, Florida still had 2.8 million uninsured residents by the end of 2015 — the third highest in the country. And since the state hasn’t expanded Medicaid, they continue to have a significant problem with hospitals having to provide uncompensated care. Since 2005, Florida’s Low Income Pool (LIP) program has relied on federal funding to help fund care for uninsured residents in the state. But because the ACA expanded Medicaid, funding for LIP had been scheduled to end on June 30, 2015.

In April 2015, Governor Scott announced that his administration was suing CMS in order to continue to receive LIP funding. Scott’s argument was that the termination of the federal LIP funding amounted to coercion to try to get Florida to expand Medicaid. Governor Scott’s lawsuit cost Florida taxpayers $175,000.

The suit was withdrawn in June 2015 after CMS announced in May that Florida would receive $1 billion in LIP funding for the 2016 fiscal year. CMS notified the state at that point that LIP funding would drop to $600 million for the 2017 fiscal year, and that LIP funding would end altogether in mid-2017. The LIP funding that was awarded in 2015 couldn’t be directly used for expenses that would have been covered by Medicaid if Florid had expanded Medicaid.

As part of the agreement with CMS for the LIP funding, Florida had to use $400 million in state funds to increase Medicaid provider reimbursement rates, which generated an extra $600 million in federal matching funds from CMS. In addition to the $1 billion in federal funding for LIP in the 2016 fiscal year, the total amount of money to fund hospital indigent care in Florida was about $2 billion, the same as it was in the 2015 fiscal year.

If Florida had expanded Medicaid, the need for the LIP program would have diminished, since there would be far fewer uninsured, low-income residents in the state. Medicaid expansion is also the reason that Disproportionate Share Hospital (DSH) payments are being phased out across the country. But that was never an option that the GOP-led legislature in Florida was willing to seriously consider.

Although LIP funding was scheduled to end in mid-2017, Governor Scott was confident that under the Trump Administration, the federal government would find a way to continue to help Florida cover the cost of providing care for low-income, uninsured patients. And sure enough, within three months of President Trump taking office, Florida had secured $1.5 billion in annual LIP funding. After the funding was announced, Governor Scott said “it is refreshing to now have a federal government that treats us fairly and does not attempt to coerce us into expanding Medicaid.” But again, it’s worth noting that if Florida were to expand Medicaid, the need for LIP funding would decrease significantly, and hundreds of thousands of currently uninsured Florida residents would have health coverage.

No ACA Medicaid expansion

As originally written, the Affordable Care Act included Medicaid expansion as a key strategy to reduce the number of uninsured people in the U.S. The ACA allowed the federal government to reduce funding for states’ existing Medicaid programs if they did not expand Medicaid to cover adults with household income up to 138 percent of the federal poverty level.

However, the U.S. Supreme Court ruled in 2012 that the withholding of funds for existing Medicaid programs was unconstitutional. Medicaid expansion was left as an option for states, and Florida did not implement it. As of January 2017, Florida is one of 19 states that have not expanded Medicaid.

According to Families USA, Florida’s decision not to expand Medicaid means about 1.25 million Floridians don’t qualify for Medicaid, despite having incomes under 138 percent of the poverty level. Nearly four hundred thousand of them are in the coverage gap — ineligible for Medicaid and also ineligible for tax subsidies to help them afford private health insurance (people with income over 100 percent of the poverty level are currently eligible for premium subsidies in the exchange, but those with income between 100 percent and 138 percent of the poverty level would switch to Medicaid eligibility if Florida were to expand coverage).

Florida’s economy is negatively impacted by not expanding Medicaid. According to an analysis by the Robert Wood Johnson Foundation and the Urban Institute, Florida was projected to lose out on $66.1 billion in Medicaid funding  — more than any other state — over the decade beginning in 2014 as a result of their decision to not expand Medicaid.

But Medicaid enrollment grows

Although Florida has not expanded Medicaid under the ACA, enrollment in the state’s program has continued to grow. Enrollment stood at 2.2 million in 2005, and had grown to 3.7 million by the end of 2013. By May 2018, it had surpassed 4.2 million.

Part of the reason Medicaid enrollment has grown is the extensive outreach on the part of ACA navigators; some residents were already eligible for Medicaid or CHIP prior to 2014 (and still are), but weren’t aware of their eligibility until enrollment outreach efforts under the ACA. But since Florida hasn’t expanded Medicaid, the newly-insured population is covered according to the normal state/federal split.

If Florida had expanded Medicaid, coverage for the newly eligible population would have been fully funded by the federal government through the end of 2016. The state’s portion would then gradually increase to ten percent by 2020, remaining at that level going forward.

History of Florida’s Medicaid program

Florida was one of the later states to implement a Medicaid, not adopting the program until January of 1970 (the first states to implement Medicaid did so in early 1966).

Florida Medicaid spending grew 13.5 percent on average every year between 1980 and 2004. In an effort to slow that trend, Florida applied for and received approval for an 1115 waiver for its Medicaid Reform pilot. The pilot implemented managed care in two counties in 2006 and added three more counties in 2007; the waiver was extended several times.

In 2013, the federal government approved an amendment for statewide expansion of managed care; the amendment also renamed Medicaid Reform as Managed Medical Assistance (MMA). More than three-quarters of all Florida Medicaid beneficiaries are now enrolled in managed care plans, like health maintenance organizations (HMOs). The state hopes to improve quality through better coordination of care and save money through smaller networks of providers.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.