Florida Legal Services’ Screening Tool for Medicaid Expansion Eligibility and A

Screening for Eligibility for Medicaid 
 
Expansion/Interested in Advocacy?
 
Introduction: Under the Affordable Care Act, states have been given the option to expand their 
Medicaid programs to cover non-disabled adults without children with incomes up to 138% of 
the federal poverty level. We are working to identify people who might potentially qualify for 
this new Medicaid Expansion, should Florida choose to expand their current program. Do you 
mind if I ask you a few questions to see if you might qualify?
Name:
Address:
Phone:
How old are you?
Adults ages 18 to 65 are eligible.
How many people live in your household?
What is your monthly income?
Use chart below to determine if their income qualifies. Monthly income limits for Medicaid 
Expansion (up to 138% FPL) based on household size are:
1 $1,285
2 $1,740
3 $2,196
4 $2,651
5 $3,106
6 $3,562
7 $4,017
8 $4,473
Are you a citizen or have you legally resided in the U.S. for 5 years or more? YES NO
Immigration requirements are the same as for regular Medicaid. 
Do you currently have health insurance? YES NO

(If uninsured) What kinds of problems have you faced due to your lack of health 
insurance?
How would having Medicaid help you?
(If the person appears to be eligible under the ACA Medicaid expansion) Would you be 
willing to: 
Share your story? YES NO
Talk to the press (TV, news, other) YES NO
Talk to elected officials YES NO
Can I share this information and your contact information with Florida Legal Services (a 
statewide legal services program helping to lead the effort around Medicaid Expansion)?
If yes, please make a copy of this information and sent to Betsy Havens, Attorney at 
Florida Legal Services, [email protected]
Other information/notes:
Organization:
Staff name:
Thank you!

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