Medicaid State Plan Under Title XIX of the Social Security Act
Medical Assistance Program

Florida's Medicaid State Plan (the Plan) is a large, comprehensive written statement describing the scope and nature of the Medicaid program. The Plan outlines current Medicaid eligibility standards, policies and reimbursement methodologies to ensure the state program receives matching federal funds under Title XIX of the Social Security Act.

Under the Florida Sunshine Law, the Plan is a public record. This Web site provides a secure link to a complete copy of the Plan, Part I and Part II, as well as a divided version further below. The divided version is sorted in the most logical format, while still following the correct order of the document. Both copies are searchable by word or phrase using the “Search” function in Adobe Acrobat Reader. If additional help is needed, please contact Robin Ingram in the Office of the Deputy Secretary for Medicaid at (850) 412-4000.

Florida Medicaid State Plan Part I [15.41MB] Upated 5/15/2012
(Due to the larger file size, this document may take more time to download.)
Updated May 15, 2012
 

Florida Medicaid State Plan Part II [24.26MB]
(Due to the larger file size, this document may take more time to download.)
Updated April 6, 2012

Table of Contents [151KB]

Section 1 – Single State Agency Organization [390KB] Upated 5/15/2012

1.1 Designation and Authority
1.2 Organization for Administration
1.3 Statewide Operation
1.4 State Medical Care Advisory Committee and Tribal Consultation Requirements
1.5 Pediatric Immunization Program

Section 2 – Coverage and Eligibility [172KB]

2.1 Application Determination of Eligibility and Furnishing Medicaid
2.2 Coverage and Conditions of Eligibility
2.3 Residence
2.4 Blindness
2.5 Disability
2.6 Financial Eligibility
2.7 Medicaid Furnished Out of State

Section 3 – Services: General Provisions [670KB]

3.1 Amount, Duration and Scope of Services
3.2 Coordination of Medicaid with Medicare Part B
3.3 Medicaid for Individual Age 65 or Over in Institutions for Mental Disease
3.4 Special Requirement Applicable to Sterilization Procedure
3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries Families Receiving Extended Medicaid Benefits

Section 4 – General Program Administration [2.34MB]

4.1 Methods of Administration
4.2 Hearings for Applicants and Recipients
4.3 Safeguarding Information on Applicants and Recipients
4.4 Medicaid Quality Control
4.5 Medicaid Agency Fraud Detection and Investigation Program
4.6 Reports
4.7 Maintenance of Records
4.8 Availability of Agency Program Manuals
4.9 Reporting Provider Payments to the Internal Revenue Service
4.10 Free Choice of Providers
4.11 Relations with Standard-Setting and Survey Agencies
4.12 Consultation to Medical Facilities
4.13 Required Provider Agreement
4.14 Utilization/Quality Control
4.15 Inspection of Care in Intermediate Care Facilities for the Mentally Retarded, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Hospitals
4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
4.17 Liens and Adjustments or Recoveries
4.18 Recipient Cost Sharing and Similar Charges
4.19 Payment for Services
4.20 Direct Payments to Certain Recipients for Physicians' or Dentists' Services
4.21 Prohibition Against Reassignment of Provider Claims
4.22 Third Party Liability
 
 Memorandum of Understanding
4.23 Use of Contracts
4.24 Standards for Payments for Skilled Nursing and Intermediate Care Facility Services
4.25 Program for Licensing Administrators of Nursing Homes
4.26 Drug Utilization Review Program
4.27 Disclosure of Survey Information and Provider or Contractor Evaluation
4.28 Appeals Process
4.29 Conflict of Interest Provisions
4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals
4.31 Disclosure of Information by Provider and Fiscal Agents
4.32 Income and Eligibility Verification System
4.33 Medicaid Eligibility Cards for Homeless Individuals
4.34 Systematic Alien Verification for Entitlements (SAVE )
4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation
4.35 Enforcement of Compliance for Nursing Facilities
4.36 Required Coordination Between the Medicaid and WIC Programs
4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities
4.39 Preadmission Screening and Annual Resident Review in Nursing Facilities
4.40 Survey & Certification Process
4.41 Resident Assessment for Nursing Facilities
4.42 Employee Education About False Claims Recoveries
4.43 Cooperation with Medicaid Integrity Program Efforts
4.44 Prohibition on Payments to Institutions Outside the US

Section 5 – Personnel Administration [83KB]

5.1 Standard of Personnel Administration
5.2 RESERVED
5.3 Training Programs; Subprofessional and Volunteer Programs

Section 6 – Financial Administration [69KB]

6.1 Fiscal Policies and Accountability
6.2 Cost Allocation
6.3 State Financial Participation

Section 7 – General Provisions [107KB]

7.1 Plan Amendments
7.2 Nondiscrimination
7.3 Maintenance of AFDC Effort
7.4 State Governor's Review

Attachments

List of Attachments [136KB]

1.1-A Attorney General's Certification [53KB]
1.1-B Waivers under the Intergovernmental Cooperation Act [4.23MB]
  Supplement 1 Medicaid Eligibility
  Supplement 2 Women, Infants, and Children (WIC) Program
  Supplement 3 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
  Supplement 4 Healthy Start
  Supplement 5 Utilization Control for Institutional Care
1.2-A
 Organization and Function of Medicaid State Agency [114KB]
1.2-B
 Organization and Function of Medicaid Office [637KB]
1.2-C
 Professional Medical and Supporting Staff [79KB]
1.2-D
 Description of Staff Making Eligibility Determination [39KB]
   
2.1-A Definition of a Health Maintenance Organization [93KB]
2.2-A Groups Covered and Agencies Responsible for Eligibility Determinations [1.32MB]
  Supplement 1 Reasonable Classifications of Individuals under the Age of 21, 20, 19 and 18
  Supplement 3 Method of Determining Cost Effectiveness of Caring for Certain Disabled Children at Home
2.6-A
 Eligibility Conditions and Requirements [3.23MB]
  Supplement 1 Income Eligibility Levels – Categorically Needy, Medically Needy and Qualified Medicare Beneficiaries
  Supplement 2 Resource Levels Categorically Needy, Including Groups with Incomes Up to a Percentage of the Federal Poverty Level, Medically Needy, and other Optional Groups
  Supplement 3 Post Eligibility Treatment of Institutionalized Individuals' Incomes
  Supplement 4 Section 1902(f) Methodologies for Treatment of Income that Differ from those of the SSI Program
  Supplement 5 Section 1902(f) Methodologies for Treatment of Resources that Differ from those of the SSI Program
  Supplement 5a Methodologies for Treatment of Resources for Individuals with Incomes Up to a Percentage of the Federal Poverty Level
  Supplement 6 Standards for Optional State Supplementary Payments
  Supplement 7 Variations from the Basic Personal Needs Allowance – Territories
  Supplement 8 Resource Standards for 1902(f) States Categorically Needy
  Supplement 8a More Liberal Methods of Treating Income Under Section 1902(r)(2) of the Act
  Supplement 8b More Liberal Methods of Treating Resources Under Section 1902(r)(2) of the Act
  Supplement 8c Long-Term Care Insurance Partnership
  Supplement 9 Transfer of Resources
  Supplement 9b Transfer of Assets
  Supplement 10 Consideration of Medicaid Qualifying Trusts--Undue Hardship
  Supplement 12 Eligibility Under Section 1931 of the Act
  Supplement 13 Section 1924 Provisions (Income and Resource Eligibility)
  Supplement 14 Income and Resource Requirements for Tuberculosis (TB) Infected Individuals
  Supplement 15 Variations from the Basic Personal Needs Allowance
  Supplement 17 Disqualification for Long-Term Care Assistance for Individuals with Substantial Home Equity
   
3.1-A
 Amount, Duration, and scope of Medical and Remedial Care and Services Provided to the Categorically Needy [6.73MB]
 
3.1.A.1
 Medicaid Program: Requirements Relating to Covered Outpatient Drugs for the Categorically Needy [62KB]
  Supplement 1 Case Management Services
  Supplement 2 Alternative Health Care Plans for Families Covered Under Section 1925 of the Act
  Supplement 3 PACE Services
  Supplement 4 1915(j) Self-Directed Personal Assistance Services
  Appendix A-1 and A-2 to Supplement 2 - Medicaid Eligibility Groups Served
  Appendix B1 through B3 to Supplement 2 - Functional Disability
  Appendix C1 and C2 to Supplement 2 - Definition of Services
  Appendix D1 and D2 to Supplement 2 - Assessment
  Appendix E1 through E3 to Supplement 2 - Individual Community Care Plan (ICCP)
  Appendix F1 through F3 to Supplement 2 - Rights Specified in the Statute
  Appendix G1 through G5 to Supplement 2 - Community Care Settings
3.1-B
 Amount, Duration, and Scope of Services Provided Medically Needy Groups [2.72MB]
 
3.1.B.1
 Medicaid Program: Requirements Relating to Covered Outpatient Drugs for the Medically Needy [64KB]
3.1-C
 Standards and Methods of Assuring High Quality Care [43KB]
3.1-D
 Methods of Providing Transportation [31KB]
3.1-E
 Standards for the Coverage of Organ Transplant Procedures [203KB]
  Supplement 1 Organ-Tissue Transplantation Standards [87KB]
3.2-A
 Coordination of Title XIX with Part A and Part B of Title XVIII [43KB]
   
4.11-A
 Standards for Institutions [24KB]
4.14-B
 Methods of Utilization Review in Facilities and Institutions [23KB]
4.16-A
 Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title Five Grantees, Parts I – XIII [2.11MB]
Interstate Compact on Adoption and Medical Assistance [296KB]
4.17-A
 Liens and Adjustments or Recoveries [426KB]
4.18-A
 Charges Imposed on Categorically Needy [153KB]
4.18-B
 Methods for Establishing Payment Rates - Emergency Services [12KB]
4.18-C
 Charges Imposed on Medically Needy and other Optional Groups [150KB]
4.18-D
 Premiums Imposed on Low Income Pregnant Women and Infants [44KB]
4.18-E
 Premiums Imposed on Qualified Disabled and Working Individuals [44KB]
4.19-A
 Methods and Standards for Establishing Payment Rates [2.10MB]
Part I: Inpatient Hospital Care
Part II: Emergency Services
4.19-B
 Methods and Standards for Establishing Payment Rates – Other Types of Care [6.88MB]
  Supplement 1 Payment of Medicare Part A and Part B Deductible/Coinsurance
Supplement 2 Federally Qualified Health Center and Rural Health Clinic
Supplement 3 County Health Department Reimbursement Plan
Exhibit I: Outpatient Hospital Reimbursement Plan
4.19-C
 Payments for Reserved Beds [45KB]
4.19-D Methods and Standards for Establishing Payment Rates [3.50MB]
  Part I: Long Term Care
Part II: Intermediate Care Facility for the Mentally Retarded and Developmentally Disabled Publicly Owned
Part III: Intermediate Care Facility for the Mentally Retarded and Developmentally Disabled Not Publicly Owned
4.19-E Timely Claims Payment - Definition of Claim [212KB]
4.20-A Conditions for Direct Payment- for Physicians and Dentist Services [9KB]
4.22-A Requirements for Third Party Liability - Identifying Liable Resources [136KB]
4.22-B Requirements for Third Party Liability - Payment for Claims [124KB]
4.22-C Employer Based Group Health Insurance [92KB]
4.30 Sanctions for Psychiatric Hospitals [76KB]
4.32-A Income and Eligibility Verification System Procedures: Requests to other State Agencies [58KB]
4.33-A Method of Issuance of Medicaid Eligibility Cards to Homeless Individuals [19KB]
4.34-A Requirements for Advance Directives Under State Plans for Medical Assistance [183KB]
4.35-A through
4.35-H		 Enforcement of Compliance for Nursing Facilities [153KB]
4.38 Disclosure of Additional Registry Information [38KB]
4.38-A Collection of Additional Registry Information [12KB]
4.39 Definition of Specialized Services [15KB]
4.39-A Categorical Determinations [52KB]
4.40-A through
4.40-E		 Eligibility Conditions and Requirements [217KB]
4.42-A Employee Education About False Claims Recovery [22KB]
   
7.2-A Methods of Administration [18KB]

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