Fla. Admin. Code Ann. R. 65A-1.205 - Eligibility Determination Process

(1) The individual completes and submits a Department application for public assistance using either the ACCESS Florida Application, CF-ES 2337, 08/2016, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11698, or an ACCESS Florida Web Application (only accepted electronically), CF-ES 2353, 11/2020, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11627. The following non-English versions of the ACCESS Florida Application are incorporated by reference: CF-ES 2337C (Chinese), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11669, CF-ES 2337F (French-Canadian), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11700, CF-ES 2337H (Creole), 08/2016, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11701, CF-ES 2337I (Italian), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11702, CF-ES 2337P (Portuguese), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11703, CF-ES 2337R (Russian), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11704, CF-ES 2337S (Spanish), 08/2016, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11705, CF-ES 2337SC (Serbo-Croatian), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11726, and CF-ES 2337V (Vietnamese), 11/2011, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11727, Individuals applying for Family-Related Medical Assistance only or the Children's Health Insurance Program (CHIP) must complete and submit the Family-Related Medical Assistance Application, CF-ES 2370, 09/2015, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11729. The following non-English versions of the Family-Related Medical Assistance Application are incorporated by reference: CF-ES 2370H (Creole), 09/2015, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11730, and CF-ES 2370S (Spanish), 09/2015, is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11731. The Medical Assistance Referral form, CF-ES 2039, 08/2018, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11634, is submitted to initiate an Emergency Medical Assistance for Noncitizens determination and is used by providers to request a Florida Medicaid ID number assignment for newborns.

Applicants may apply for public assistance in person or by phone, mail, the internet, or fax. Individuals may also apply for Medicaid through the Federally Facilitated Marketplace (FFM).

An application for public assistance benefits must contain at least the individual's name, address, and signature to initiate the application process. An eligibility specialist determines the eligibility of each household member for public assistance. An applicant can withdraw the application at any time without affecting their right to reapply.

An application for Medicaid coverage on behalf of a child(ren) in the care of the Department is made by completing and submitting the Child In Care Medicaid Application, CF-ES 2293, 01/2020, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11635.

(a) The Department must determine an applicant's eligibility for public assistance initially at application and, if the applicant is determined eligible, at periodic intervals thereafter. If an applicant is determined ineligible for Medicaid benefits based on the modified adjusted gross income (MAGI) budgeting methodology as defined in subsection 65A-1.701(45), F.A.C., the Department will forward an electronic file to the Children's Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM) for a determination of eligibility. It is the applicant's responsibility to keep appointments with the eligibility specialist and furnish information, documentation and verification needed to establish eligibility. If the Department schedules a telephonic appointment, it is the Department's responsibility to be available to answer the applicant's phone call at the appointed time. The Department will provide the applicant a written notice of action taken on the case including information on fair hearing rights. The eligibility specialist must provide assistance in obtaining information, documentation or verification when requested by the applicant or when assistance appears necessary.

(b) The Department must verify the Social Security Numbers (SSNs) for each applicant for public assistance benefits, except individuals applying for Medicaid who:

1. Are not eligible to receive a SSN,

2. Do not have a SSN,

3. May only be issued an SSN for a valid non-work reason in accordance with 20 C.F.R. § 422.104, or

4. Individuals who refuse to obtain an SSN because of well-established religious objections.

(c) The Department follows time standards for processing public assistance applications which vary by public assistance program type. The time standards for processing applications for the Food Assistance Program and Temporary Cash Assistance Program are set forth in 7 C.F.R. § 273.2(g)(1) and 45 C.F.R. § 206.10(a)(3)(i) and (ii), respectively. The time standard for processing applications for Medicaid is set forth in 42 C.F.R. § 435.912 (a), (b), and (c). For Food Assistance and Temporary Cash Assistance Programs, time standards begin the date following the date the application was filed and end on the date the Department makes benefits available or mails a notice concerning eligibility, whichever is earlier.

For the Medicaid Program, the time standard begins on the date of application and ends on the date the Department mails an eligibility notice. The Department must process and determine eligibility within the following time frames:

1. Expedited Food Assistance - 7 days.

2. Food Assistance - 30 days.

3. Refugee Assistance, Medicaid not based on disability, Temporary Cash Assistance, Optional State Supplementation, Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI1) and Qualified Disabled and Working Individuals (WD) - 45 days.

4. Medicaid based on disability - 90 days.

All days counted after the date of application are calendar days. Applicant delay days do not count in determining the Department's compliance with the time standard. The Department uses information provided on the Screening for Expedited Medicaid Appointments form, CF-ES 2930, 04/2007, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11636, to expedite processing of Medicaid disability-related applications. The following non-English versions of the Screening for Expedited Medicaid Appointments form are incorporated by reference: CF-ES 2930H (Creole), 04/2007, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11637; and CF-ES 2930S (Spanish), 04/2007, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11638. The "Are You Disabled and Applying for Medicaid?" brochure, CF/PI 165-107, 06/2008, incorporated by reference and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11725, describes required information for Medicaid Program eligibility determinations. The following non-English versions of the "Are You Disabled and Applying for Medicaid?" brochure are incorporated by reference: CF/PI 165-107H (Creole), 06/2008, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11723; and CF/PI 165/107S (Spanish), 06/2008, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11724.

(d) If the eligibility specialist determines during the interview or at any time during the processing of the application that the applicant must provide additional information or verification, or that a member of the assistance group must register for employment services, the eligibility specialist must give the applicant written notice to provide the requested information or verification, or to comply with the work registration process, allowing 10 calendar days from the date of a notice for additional information or verification or the interview date, whichever is later, to comply.

(e) For all programs, if the requested verifications are not returned within 10 calendar days from the date of written request or the interview, or 30 calender days from the date of application, whichever is later, the application will be denied unless the applicant requests an extension prior to the due date or there is physician delay or emergency delay, as defined in subparagraphs (h)2. and (h)3. below, justifying the additional extension. If the applicant completed the interview, if required, but failed to provide the required verifications and was denied, the applicant may provide the verifications within 60 calendar days after the original date of application and reuse the application that was denied. For food assistance and temporary cash assistance, the new date of application is the date the applicant provided all required verifications.

(f) For Medicaid only applications, when the applicant must provide medical information, the due date is 30 calendar days following the date of a written request for such information or the interview date, or 60 calendar days from the date of application, whichever is later.

(g) If the due date falls on a state holiday or weekend, the due date deadline is the next business day.

(h) In accordance with 42 C.F.R. § 435.912 (e)(1) and (2), the types of unusual circumstance that might affect the application processing time for Medicaid applications include applicant delay, physician delay and emergency delay as defined below. Unusual circumstances are non-agency application processing delays, and the calendar time passing during such delay period(s) does not count as part of the application processing time standard for determining the timeliness of Medicaid eligibility decisions.

1. "Applicant delay" days are the number of calendar days attributed to the applicant that causes the eligibility decision to be made after the established time standard. Applicant delay can result from an applicant missing a scheduled appointment or failure to provide requested eligibility information, including requested medical information or requested verification. Applicant delay begins the date the applicant misses the deadline for the required action and ends the date the applicant takes the required action.

2. "Physician delay" days are the number of calendar days attributed to the applicant's physician(s) that causes the eligibility decision to be made after the established time standard. Physician delay can result from a physician not providing requested medical evidence or from not conducting a medical examination timely. Physician delay begins 10 calendar days after the Department makes its initial request for medical evidence from the physician and ends the date the Department receives complete medical evidence that is responsive to the Department's request; or, physician delay begins 14 calendar days after the Department requests a medical examination and ends the date the Department receives the complete medical examination results.

3. "Emergency delay" days are the number of calendar days attributed to situations that are beyond the control of the Department that causes the eligibility decision to be made after the established time standard. Emergency delay can result from disasters, unexpected office closure(s), and unexpected or unscheduled computer systems inaccessibility or unavailability. Emergency delay begins the day such an event begins and ends the day the Department is able to resume application processing.

(2) In accordance with 7 C.F.R. § 273.14(b), 45 C.F.R. § 206.10(a)(9)(iii), and 42 C.F.R. § 435.916(a) or (b), and 42 C.F.R.§ 435.919, the Department must redetermine eligibility at periodic intervals.

(a) A complete eligibility review is the process of reviewing all factors related to continued eligibility of the assistance group.

(b) A partial eligibility review entails a review of one or more, but not all factors of eligibility. The Department schedules partial reviews based on known facts or anticipated changes in circumstances concerning the assistance group. The partial review does not usually require an interview unless needed to obtain the necessary information. The Department will complete a review of an unanticipated change concerning the assistance group when the change is reported.

(c) The Department will make a renewal of eligibility for Medicaid without requiring information from the individual if it is possible to do so based on reliable information contained in the individual's case or other more current information available to the Department and send the individual a written notice concerning eligibility. The Department will request only the information needed to renew eligibility. If a renewal cannot be made based upon existing and available information, the Department will provide the individual with:

1. A notice, at least 30 calendar days prior to the end of the eligibility renewal date, informing them it is time to review their eligibility for continued benefits and the options available to complete the renewal process; and

2. A notice of the Department's decision concerning the renewal of eligibility.

(d) The Department will reconsider the eligibility of an individual whose case is closed due to failure to submit the renewal application or to provide requested information, if the individual meets the renewal application conditions within three months after the date of closure in accordance with 42 C.F.R.§ 435.911 and 42 C.F.R. § 435.916(f).

(3) The Department conducts phone or face-to-face interviews with applicants and recipients, or their authorized or designated representatives, when required for the application or to complete the eligibility review process. The Department conducts face-to-face interviews, upon request, in the Office of Economic Self-Sufficiency Program Offices, at the applicant's or recipient's home, or at other mutually agreed upon locations. The applicant or recipient, or their authorized or designated representative, must keep the interview appointment or reschedule a missed appointment. The Department mails a notice of missed interview to food assistance households who miss an interview.

(4) If an applicant or recipient does not sign and date the application, fails to keep an appointment or reschedule with the eligibility specialist, fails to submit the required documentation or verification, or fails to request an extension of the due date, the Department will deny the application because it cannot establish eligibility.

(5) The Department must substantiate information provided by the applicant or recipient as part of each determination of eligibility. For any public assistance program, when there is a question about the accuracy of the information provided, the Department will ask for additional information.

(a) Substantiation establishes accuracy of information by obtaining consistent, supporting information from the individual or other third parties. The information can be obtained or provided electronically, telephonically, in writing, or by personal contact.

(b) Documentation establishes the accuracy of information by obtaining and including in the case record an official document that supports the statement(s) made by the individual.

(6) The Department conducts data exchanges with other agencies and systems to obtain relevant public assistance eligibility information on each applicant and recipient. It uses data exchanges to verify or identify social security numbers, verify the receipt of other benefits from other sources or programs, verify other eligibility information reported by the applicant or recipient, and to discover unreported relevant eligibility information. For Medicaid eligibility, information obtained from the Federal Data Services Hub (FDSH) and State Wage Information and Collection Agency (SWICA) that does not adversely affect eligibilty is considered verified upon receipt and does not require third party verification.

(a) The Department conducts data exchanges with the Social Security Administration, the Internal Revenue Service, the Florida Department of Economic Opportunity, the Florida Department of Lottery, the Federal Data Services Hub, the Florida Department of Corrections, federal and state personnel and retirement systems, other states' public assistance programs and files, and educational institutions.

(b) The Department compares information obtained through data exchanges with the information already on file. If the data exchange identifies new or different information than what is already on file, the Department conducts a partial eligibility review to determine whether benefit levels must change.

(c) The Department considers beneficiary and Supplemental Security Income (SSI) benefit data from the Social Security Administration, unemployment compensation benefits, the Department of Health, Department of Corrections, and information obtained from the Office of Vital Statistics verified upon receipt and does not require third party verification. Other information and data obtained by the Department may require third party verification before the Department will rely upon it to take adverse actions on a case. If the information provided by or on behalf of an individual is consistent with the information obtained by the Department, the Department will consider the information reasonably compatible and determine or renew eligibility, except where the law requires other procedures (such as citizenship, immigration status and identity).

(d) The Department will collect additional information as needed to determine eligibility for non-MAGI related Medicaid eligibility for:

1. Individuals whom the Department identifies based on information contained in the application as potentially eligible for non-MAGI related Medicaid coverage;

2. Individuals who request a determination of eligibility on a basis other than the MAGI rules. The Department will require individuals to provide only the information necessary to make an eligibility determination.

(7) In accordance with 42 C.F.R. § 435.907(e)(3), the Department may collect SSNs of individuals who are not requesting assistance but must provide clear notice to non-applicants that providing the SSN is voluntary as well as provide information about the Department's purpose for collecting the non-applicant's SSN.

(8) In accordance with Food Assistance Program waivers, food assistance applicants and recipients who have been interviewed, but have not returned the requested verification by the due date, can be denied prior to the 30th day. Face-to-face interviews are not required.

(9) The following additional forms, which are incorporated into this rule by reference, can be used in the eligibility determination process:

(a) Verification of Employment/Loss of Income, CF-ES 2620, 05/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11642, CF-ES 2620H (Creole), 05/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11643, CF-ES 2620S (Spanish), 05/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11644;

(b) Verification of Dependent Care Expenses, CF-ES 2621, 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11645, CF-ES 2621H (Creole), 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11646, CF-ES 2621S (Spanish), 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11647;

(c) Verification of Shelter Expenses, CF-ES 2622, 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11648, CF-ES 2622H (Creole), 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11649, CF-ES 2622S (Spanish), 03/2010, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11650;

(d) School Verification, CF-ES 2623, 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11651, CF-ES 2623H (Creole), 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11652, CF-ES 2623S (Spanish), 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11653;

(e) Work Calendar, CF-ES 3007, 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11654, CF-ES 3007H (Creole), 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11655, CF-ES 3007S (Spanish), 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11656;

(f) Designation of Beneficiary, CF-ES 990, 01/2020, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11657;

(g) Medical Assistance Referral, CF-ES 2039, incorporated in subsection (1) of this rule;

(h) Authorization to Disclose Information, CF-ES 2514, 02/2007, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11658, CF-ES 2514H (Creole), 02/2007, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11660, CF-ES 2514S (Spanish), 02/2007, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11661; and

(i) Financial Information Release, CF-ES 2613, 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11662, CF-ES 2613H (Creole), 10/2005, available at https://www.flrules.org/Gateway/reference.asp?No=Ref-11663.

Notes

Fla. Admin. Code Ann. R. 65A-1.205

Rulemaking Authority 409.919, 414.095, 414.45 FS. Law Implemented 409.903, 409.904, 409.919, 414.045, 414.095, 414.31, 414.41 FS.

New 4-9-92, Amended 11-22-93, 8-3-94, Formerly 10C-1.205, Amended 11-30-98, 9-27-00, 7-29-01, 9-12-04, 9-11-08, 7-1-10, 2-20-12, Amended by Florida Register Volume 46, Number 048, March 10, 2020 effective 3/25/2020.

New 4-9-92, Amended 11-22-93, 8-3-94, Formerly 10C-1.205, Amended 11-30-98, 9-27-00, 7-29-01, 9-12-04, 9-11-08, 7-1-10, 2-20-12, 3-25-20.