Medicaid and CMS…you want to read this!

is it income based?!  I think I figured it out!!!

medicaid

Our family had a big win last month with notification that our son with autism was eligible for Florida’s Children’s Medical Services (CMS).  My mouth fell open, I jumped up and cheered.  It felt like hitting the lottery!  For years, our family has scrambled to find therapists in network, pay high deductibles and even maxed out coverage to get our son the therapy he needed.  OH! and don’t forget about the dental work with sedation!

The Children’s Medical Services is part of Florida Health, be sure to use the official state website when getting information.  It states on this website that the child must meet the financial requirements for Medicaid in order to qualify.  However, my patrician as well as other doctors have conflicting view points on whether there is or is not a financial requirement.  This is the statue listed on the state website that I am going to share and analyze.

*The Children’s Medical Services (CMS) Safety Net Program is for
Florida residents, ages 0 to 21, who meet both clinical and financial eligibility and sliding fee criteria.  CMS provides “benefits authorized in section 391.0315, Florida Statutes, for children with chronic and serious medical conditions who do not qualify for Medicaid or Title XXI of the Social Security Act.  Children eligible for assistance using these funds must be uninsured, or insured but not covered for medically necessary services, or unable to access services due to lack of providers or lack of financial resources regardless of insurance status.  Families shall participate financially in the cost of care based on a sliding scale established by CMS.”  Contact a CMS Plan area office for more information.

Source: Florida Health

Here is where I think the confusion is…for children with chronic and serious medical conditions who do not qualify for Medicaid or Title XXI of the Social Security Act.  This line tells us that any child that  has a medical condition and does NOT qualify for Medicaid.  So, families can participate in the cost of care in order to receive access to the CMS network.  When your child does NOT qualify for Medicaid they are …eligible for assistance using these funds must be uninsured, or insured but not covered for medically necessary services, or unable to access services due to lack of providers or lack of financial resources regardless of insurance status.  This explains that if you have a current commercial insurance policy but you cannot access OT, speech and/or ABA therapy for your child with autism then you child should be able to meet the requirements for CMS.  Each family must pay a monthly fee in order to receive coverage.  I know that my new friend is out there with that $4,000 deductible and needs to know this.

Here is my best advice on how to get this started.  It’s time consuming, confusing, stressful and worth it in the end.

  1. start by completing the ACCESS Florida Medicaid and assistance application. This is a general application for the state and you have to start here.
  2. check out Florida KidCare.    This page also has an apply link.  I do not remember completing this application at all.  I do have to use this site to pay my monthly CMS fee for my son.  When in doubt, apply to both.
  3. Keep all the paperwork, you will get a lot of letters about denied, accepted with limitations, changing letterhead, and notices to call nurse coordinators.
  4. When you get your acceptance letter, call to confirm your monthly payment and pay online immediately.  The government works via mail carrier so the speed that you receive documents is slow and you do not want coverage to drop.
  5. Submit any paperwork requested quickly, be sure to make copies and mail back using the enclosed addressed envelope.

 

So, I think I figured it out!  In basic terms, CMS is to cover those children that are medically needy that do not qualify for Medicaid whose parents must pay a monthly premium to access the network.

Need help? Have Questions?

Ruthfulness single letter logo 2017 150 blog icon small

 

Published by ruthfulness

A journey of education, access, advocating and love! Maximize your knowledge of autism through stories, tips and action.

3 thoughts on “Medicaid and CMS…you want to read this!

  1. I came across this post in my search for CMS coverage for those ineligible for Medicaid. It is VERY confusing, so I appreciated your post. But, I did follow the steps you outlined above and was told point-blank by CMS that it is income-based (because it’s a Medicaid service). They’re offering me KidCare Simply as a supplemental (for $230/ month for one child!) or possibly the CMS Safety Net program, which has very limited coverage and will only cover services that our primary ins denies. That’s it! My son has CP, so would fall under the “chronic condition,” but it looks like if your income is over $40-50k, you’re out of luck with getting any help. Any other advice you can give would be extremely appreciated.

    Like

    1. With changes in state insurance coverage moving to wellcare there are so many new rules and ways they are denying care.
      In private insurance companies are making policies to deny services.
      I’m still trying to get APD destination.
      So, I’m understanding that if your child is disabled there is supposed to coverage you the disabled child via medicaid.
      Now the learning curve for how to get a child labeled as disabled by the state.

      Like

  2. Thank you so much! This is very helpful information. I, too am struggling with the medicaid / kidcare issues for my son. He actually had Kidcare with CMS title 21 for several years. so long, my income for two stayed below $40K after obtaining my degree my employer promoted me and gave me a raise. Unfortunaly, my income was now above the requirements for the program. My son was literally kicked off Kidcare with CMS title 21, which caused an interruption is his ABA Services and other therapies. He is diagnosed with Autistic Disorder as primary and ADHD as secondary. I’ve been engaged in an email / phone war with both Access Florida and CMS to try and get my son back onto medicaid as I have three medical professionals who cite he “Medically needs” the ABA therapies on a daily basis. My son’s mental health has detrioriated and he has become now more agressive towards me without these services. It’s unfair to Single Mom’s like myself that these organizations don’t care the effects of having a child like mine be off his therapies. I work hard to provide for him, I am working middle class, and pay taxes yet, my son doesn’t qualify because I make too much money. They don;t calculate my net income or the fact that I alone have a mortgage, car payment, kidcare full premium $230, my son’s private school tuition because his McKay doen’t cover all of it, utilities bills, etc….

    Like

Leave a Reply to Nelly Cabral Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: