Medicare, Medicaid, Social Security & Other Health Concepts
8% of the exam
The government-program block of the Florida 2-15 exam: Medicare's four parts, Florida's Medigap rules, Medicaid eligibility, Social Security disability timing, the four disability definitions, workers' compensation, coordination of benefits, and who pays tax on health benefits. Plan for roughly 8% of the exam — about 12 of the 150 scored questions. Treat that share as a study-planning estimate, not an official published weight.
Medicare: the four parts, mapped
Medicare is federal, age- or disability-based, and runs in four parts. Part A — hospital. Inpatient stays, skilled nursing care, home health, hospice. No monthly premium with 40 quarters of coverage (10 years) in Medicare-covered employment. Part B — medical. Doctor visits, outpatient care, lab work, durable medical equipment. Pays 80% of the Medicare-approved amount after an annual deductible; the beneficiary pays a monthly premium. Part C — Medicare Advantage. A private plan that replaces how Parts A and B are delivered, usually through an HMO or PPO network. Most bundle drug coverage. Part D — prescription drugs. Private, voluntary, and penalized for late enrollment. Eligibility, and when coverage actually starts: - Age 65, if entitled to Social Security or Railroad Retirement benefits. - Disability: after 24 months of entitlement to Social Security disability benefits. - ALS: the 24-month wait is waived, so Medicare begins with the first month of SSDI entitlement — not on the date of diagnosis. - ESRD: coverage generally begins the fourth month of dialysis, earlier with a home-dialysis training course or a kidney transplant.
Medicare Supplement (Medigap) — the Florida rules
Medigap fills Original Medicare's gaps — deductibles, coinsurance, lifetime reserve days. Plans are standardized by letter, so every insurer's Plan G buys identical coverage and the only real difference is price and service. Medigap never pairs with Medicare Advantage; a client holds one or the other. Florida duties an agent must know: 1. 30-day free look via a prominently displayed no-loss cancellation clause, with full refund of premiums paid (s. 627.674, F.S.). 2. Six-month open enrollment beginning with the first month the client is 65 and enrolled in Medicare Part B — no health underwriting (s. 627.6741(1), F.S.). 3. Florida extends that same right to under-65 enrollees eligible for Medicare by reason of disability or ESRD (s. 627.6741(1), F.S.). 4. A separate two-month window following termination of coverage under a group health insurance policy (s. 627.6741(1), F.S.). 5. Preexisting conditions excluded no longer than six months, and the definition may reach back no further than six months before the effective date. On a replacement, the new insurer must waive that time to the extent it was already served under the original policy (s. 627.6741(2), F.S.). 6. Cancellation or nonrenewal only for nonpayment of premium or material misrepresentation (s. 627.6741, F.S.).
Medicaid in Florida: means-tested, not earned
Medicare is an entitlement earned through work credits. Medicaid is a needs-based program — joint federal and state money, state-administered, and tested on financial need. Watch the asset test, because it does not apply everywhere. Income is tested in every Medicaid category. An asset (resource) test applies to the aged, blind and disabled categories and to long-term-care Medicaid. The MAGI-based categories — children, pregnant women, parents and caretaker relatives — have no asset test at all. Florida facts that show up on the exam: - Florida has not adopted ACA Medicaid expansion. Non-disabled childless adults generally have no eligibility pathway at any income level — the coverage gap. - Most enrollees receive services through Statewide Medicaid Managed Care (SMMC), administered by the Agency for Health Care Administration (AHCA). Enrollees choose a plan and are auto-assigned if they do not. - Nursing-home Medicaid (the Institutional Care Program) is income-capped: $2,982 per month and $2,000 in countable assets for a single applicant in 2026, with a 60-month look-back on asset transfers. - Florida KidCare is the umbrella brand for four income-based programs — Children's Medicaid, MediKids, Florida Healthy Kids and the Children's Medical Services Health Plan — covering children from birth until the 19th birthday, with subsidized CHIP families paying a modest monthly family premium.
Social Security disability and the four disability definitions
Social Security's definition: inability to engage in any substantial gainful activity because of a medically determinable impairment expected to last at least 12 months or result in death. 2026 SGA is $1,690 per month, $2,830 if blind. Two clocks run back-to-back: a 5-month waiting period before the first check, then 24 months of SSDI entitlement before Medicare begins. Total from onset to Medicare: 29 months. Both waits are waived for ALS. Insured status: fully insured = 40 quarters of coverage; currently insured = 6 quarters of coverage in the last 13 quarters. Private policy definitions: - Total — cannot perform the duties of the insured's own occupation, or of any occupation, depending on which definition the policy uses. - Partial — a flat reduced benefit, usually time-limited, and usually requiring a prior period of total disability. - Residual — benefit prorated to actual income loss. - Recurrent — a relapse inside the recurrent-disability window continues the original claim, so no new elimination period.
Occupational exposure: workers' comp, subrogation, coordination
Occupational means arising out of employment; non-occupational means off the job. Most individual health and disability policies are non-occupational only. A 24-hour policy covers both. Florida workers' compensation (ch. 440, F.S.) is the occupational system. Coverage is required at 1 or more employees in construction, 4 or more in non-construction, and in agriculture at more than 5 regular employees or 12 or more seasonal workers employed more than 30 days in a season. No benefits for the first 7 days of disability, but those days are paid retroactively if the disability lasts more than 21 days (s. 440.12(1), F.S.). Temporary total pays 66 2/3% of the average weekly wage for up to 104 weeks (s. 440.15(2), F.S.). The weekly maximum is 100% of the statewide average weekly wage for the year of injury (s. 440.12(2), F.S.). Subrogation lets the paying employer or carrier step into the employee's shoes and recover from the at-fault third party (s. 440.39, F.S.). Coordination of benefits prevents duplicate payment (s. 627.4235, F.S.). Birthday rule: the parent whose birthday — month and day, year of birth excluded — falls earlier in the calendar year is primary (s. 627.4235(4)(b), F.S.).
Managed care and the tax treatment of health coverage
Managed care controls cost by controlling access. HMO — prepaid, primary care physician as gatekeeper, in-network only except emergencies; a Florida HMO must hold a valid health care provider certificate from AHCA before the Office of Insurance Regulation may issue a certificate of authority (s. 641.21(1), F.S.). PPO — no gatekeeper, out-of-network allowed at higher cost. EPO — network-only, no gatekeeper. POS — an HMO core with an out-of-network option. Taxation (federal rules; Florida has no personal income tax): - Individual medical premiums: deductible only within unreimbursed medical expenses above 7.5% of AGI. - Employer-paid group health: deductible to the employer, not income to the employee, benefits tax-free. - Individually paid disability income premiums: not deductible, so benefits are tax-free. - Employer-paid disability income premiums: deductible to the employer, so benefits are taxable to the employee.
Where people lose points
✗ Medicare vs Medicaid — both start with "Medi", so candidates treat them as the same kind of program.
✓ Medicare is a federal entitlement EARNED through work credits — you qualify at 65 or after 24 months of SSDI, with no income or asset test for eligibility. (Income affects only what you PAY: high earners owe an IRMAA surcharge on Parts B and D.) Medicaid is a needs-based program, jointly funded and state-administered (AHCA in Florida), always income-tested and asset-tested in the aged/blind/disabled and long-term-care categories. A low-income senior can be dual-eligible for both at once.
✗ Treating Medicare Advantage (Part C) as "a supplement", or believing a client can stack Medigap on top of a Part C plan.
✓ Medigap sits on top of ORIGINAL Medicare and pays Medicare's own deductibles and coinsurance. Medicare Advantage REPLACES how Parts A and B are delivered, through a private network plan. Federal law prohibits selling a Medigap policy to someone enrolled in Medicare Advantage, and Florida separately prohibits any sale that would give an individual more than one Medicare supplement policy — Rule 69O-156.017, F.A.C. (and the parallel agent-conduct rule, 69B-156.017, F.A.C.).
✗ Mixing up the SSDI 5-month waiting period with the 24-month Medicare waiting period.
✓ Five months is the wait before the FIRST CASH BENEFIT is paid. Twenty-four months is how long a person must be entitled to SSDI before MEDICARE begins. They run back-to-back, so the total from disability onset to Medicare coverage is 29 months, not 24. ALS is the exception: both the 5-month cash wait and the 24-month Medicare wait are waived.
✗ Using "partial disability" and "residual disability" as if they were interchangeable.
✓ Partial pays a FLAT, pre-set fraction of the total benefit — often 50% — for a limited period, and it usually requires a prior period of total disability. Residual pays a benefit PROPORTIONATE to actual lost income, so a 40% earnings loss pays 40% of the benefit, and it typically does not require prior total disability. Recurrent is different again: it is the relapse clause that avoids a new elimination period.
✗ Applying the birthday rule using the child's birthday, or assuming the OLDER parent is primary.
✓ It is the PARENT whose birthday MONTH AND DAY fall earlier in the calendar year; the year of birth is expressly excluded, so the younger parent is frequently primary (s. 627.4235(4)(b), F.S.). That rule applies when the parents are not separated or divorced. If they are, the order is the parent with custody, then the spouse of the parent with custody, then the parent without custody — unless a court decree assigns responsibility for health care expenses and the insurer has actual knowledge of it (s. 627.4235(4)(c), F.S.).
✗ Treating subrogation and coordination of benefits as the same anti-duplication device.
✓ Coordination of benefits operates BETWEEN TWO PLANS covering the same person; it only decides which plan pays first and which pays the balance (s. 627.4235, F.S.). Subrogation operates AGAINST A THIRD PARTY who caused the loss: the insurer that paid the claim steps into the insured's legal shoes and recovers from the wrongdoer or the wrongdoer's liability carrier (s. 440.39, F.S., for workers' compensation).
Numbers to memorize
| Medicare supplement free look (FL) | 30 days, full refund of premiums paid, via a prominently displayed no-loss cancellation clause — s. 627.674, F.S. |
| Medigap open enrollment at 65 (FL) | 6 months, beginning with the first month the person has attained 65 AND is enrolled in Medicare Part B; no health underwriting — s. 627.6741(1), F.S. |
| Medigap open enrollment under 65 (FL) | Same guaranteed 6-month right for those eligible for Medicare by reason of disability or ESRD — s. 627.6741(1), F.S. |
| Medigap window after group coverage ends (FL) | 2 months following termination of coverage under a group health insurance policy — s. 627.6741(1), F.S. |
| Medigap preexisting condition limit (FL) | 6 months maximum, and the definition may reach back no more than 6 months before the effective date; on replacement, time already served under the original policy must be waived — s. 627.6741(2), F.S. |
| Medigap cancellation grounds (FL) | Nonpayment of premium or material misrepresentation only — s. 627.6741, F.S. |
| Medigap agent compensation (FL) | First-year compensation no more than 200% of the compensation paid for selling or servicing the policy in the second year; renewal compensation must equal the second-year amount and be provided for no fewer than 5 renewal years — Rule 69O-156.013, F.A.C. |
| Duplicate Medigap coverage (FL) | Prohibited — any sale that would provide an individual with more than one Medicare supplement policy or certificate — Rule 69O-156.017, F.A.C.; parallel agent rule 69B-156.017, F.A.C. |
| Part A hospital benefit period | Days 1-60: deductible only. Days 61-90: daily coinsurance. Then 60 lifetime reserve days, usable once in a lifetime. |
| Part A skilled nursing facility | Days 1-20 paid in full; days 21-100 daily coinsurance; nothing after day 100. Requires a qualifying 3-day inpatient hospital stay. |
| 2026 Part A amounts | $1,736 inpatient deductible per benefit period; $434/day days 61-90; $868/day lifetime reserve; $217/day SNF days 21-100 |
| 2026 Part B amounts | $202.90 standard monthly premium; $283 annual deductible; Medicare then pays 80% of the approved amount and the beneficiary 20% |
| 2026 Part D amounts | Deductible no more than $615; out-of-pocket cap $2,100, after which the plan pays 100% |
| Premium-free Part A | 40 quarters of coverage (10 years) of Medicare-covered employment |
| SSDI waiting period | 5 full months before the first benefit is paid (waived for ALS) |
| Medicare after SSDI | 24 months of disability benefit entitlement — 29 months total from disability onset (waived for ALS) |
| Medicare start for ESRD | Generally the fourth month of dialysis; earlier with a home-dialysis training course or a kidney transplant |
| Insured status | Fully insured = 40 quarters of coverage. Currently insured = 6 quarters of coverage in the last 13 quarters. |
| 2026 substantial gainful activity (SGA) | $1,690 per month; $2,830 per month if blind |
| FL workers' comp coverage thresholds | Construction: 1 or more employees. Non-construction: 4 or more. Agriculture: more than 5 regular employees, or 12 or more seasonal workers employed more than 30 days in a season — ch. 440, F.S. |
| FL workers' comp waiting period | First 7 days not compensated, but paid retroactively if the disability lasts more than 21 days — s. 440.12(1), F.S. |
| FL temporary total disability | 66 2/3% of average weekly wage, not to exceed 104 weeks — s. 440.15(2), F.S. |
| FL temporary partial disability | 80% of the difference between 80% of the average weekly wage and postinjury earnings, capped at 66 2/3% of the AWW, max 104 weeks — s. 440.15(4), F.S. |
| FL workers' comp weekly maximum | 100% of the statewide average weekly wage for the year in which the injury occurred — s. 440.12(2), F.S. |
| FL nursing-home Medicaid (2026) | Income cap $2,982/month and $2,000 countable assets for a single applicant; 60-month look-back on transfers |
| Florida KidCare | Umbrella for four income-based programs — Children's Medicaid, MediKids, Florida Healthy Kids, and the Children's Medical Services Health Plan — covering children from birth until the 19th birthday |
| Medical expense deduction | Unreimbursed medical costs, including premiums, deductible only above 7.5% of adjusted gross income |
| 2026 HSA / HDHP limits | HSA contributions $4,400 self-only, $8,750 family. HDHP minimum deductible $1,700 / $3,400; out-of-pocket max $8,500 / $17,000 |
| Coordination of benefits — birthday rule | Primary is the parent whose birthday, excluding year of birth, falls earlier in the calendar year — s. 627.4235(4)(b), F.S. Divorced or separated: custodial parent, then that parent's spouse, then the non-custodial parent — s. 627.4235(4)(c), F.S. |
| Florida HMO licensing sequence | AHCA health care provider certificate first; the Office of Insurance Regulation may not issue a certificate of authority without it — s. 641.21(1), F.S. |
| Free Medicare counseling in Florida | SHINE (Serving Health Insurance Needs of Elders), the SHIP program administered by the Florida Department of Elder Affairs — Elder Helpline 1-800-963-5337 (1-800-96-ELDER). Free, unbiased and confidential; counselors sell nothing. |
Test yourself
No answers here on purpose — retrieving them is the practice. Drill this domain if any of these stall you.
- Name what each of Medicare Parts A, B, C and D covers, and say which one is voluntary prescription drug coverage sold by private insurers.
- Walk the Part A hospital benefit period from day 1 through day 150, naming what the beneficiary owes at each stage. Then do the same for a skilled nursing facility stay.
- A 52-year-old is on Medicare through disability and wants a Medigap policy in Florida. State her open enrollment right, the free-look length, and the maximum preexisting condition exclusion — with the statute cites.
- Three clients reach Medicare three different ways — turning 65, ALS, and ESRD. State when coverage begins for each.
- Why does a healthy, low-income 35-year-old with no children usually fail to qualify for Florida Medicaid, and what is the income and asset test for nursing-home Medicaid in Florida? Which Medicaid categories apply no asset test at all?
- Define disability the way Social Security defines it, then state both waiting periods and the total number of months from onset to Medicare coverage.
- Distinguish total, partial, residual and recurrent disability, and say which one lets a returning claimant skip a new elimination period.
- Both parents of a covered child have group health plans. Explain Florida's order of benefit determination, then change the facts to divorced parents and explain it again.
- Explain occupational vs non-occupational coverage, then state Florida's workers' compensation waiting period, its retroactive trigger, and the temporary total disability rate and duration.
- Who deducted the premium, and therefore who pays the tax on the benefit? Run it for employer-paid group disability income, individually paid disability income, and employer-paid group health.