15-001666 Memorial Hospital Flagler, Inc., D/B/A Florida Hospital Flagler vs. Agency For Health Care Administration Status: Closed Settled and/or Dismissed prior to entry of RO/FO on Wednesday, April 1, 2015.

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION 2919 Sc$ 13 P ( z'

MEMORIAL HOSPITAL

FLAGLER, INC. d/ b/ a FLORIDA

HOSPITAL FLAGLER, PROVIDER NO.: 101893

Petitioner, AHCA NO.: 15- 113

RENDITION NO.: AHCA- 7 3' 1 - S- MDA

vs.

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent.

FINAL ORDER

THE PARTIES resolved all disputed issues and executed a Settlement Agreement. The

parties are directed to comply with the terms of the attached settlement agreement. Based on the

foregoing, this file is CLOSED.

DONE and ORDERED on this the day of , 2019, in Tallahassee,

Leon County, Florida.

e'

MAR MAYHEW, SECRETARY

A2eifev for Health Care Administration

Florida Hospital Flagier, Inc. AHCA vs. Agency No.: 15- for 113) Health Care Administration

FINAL ORDER

Page 1 of 3

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED

TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY

OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND

COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT

COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY

MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW

PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA

APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS

OF RENDITION OF THE ORDER TO BE REVIEWED.

Copies furnished to:

Florida Hospital- Flagler Steven T. Mindlin

Attn: Hospital Administrator Kyle L. Kemper

60 Memorial Medical Parkway Sundstrom & Mindlin, LLP

Palm Coast, FL 32164 smindlinL& asfflaw. com

U. S. MAIL) kkemperLwsfflaw. com

E - Mail)

Joseph M. Goldstein, Esquire

Shutts & Bowen LLP Bureau of Health Quality Assurance

200 East Broward Blvd., Suite 2100 Agency for Health Care Administration

Fort Lauderdale, FL 33301 E - Mail)

igoldsteinLc6shutts. com

E - Mail)

Shena L. Grantham, Esquire Division of Health Quality Assurance

MAL & MPI Chief Counsel Bureau of Central Services

Shena. Grantham( u ahcaanyflorida. com CSMU- 86L& ahca. myflorida. com

E - Mail) E - Mail)

Stefan Grow, General Counsel Division of Administrative Hearings

Agency for Health Care Administration The Desoto Building

E - Mail) 1230 Apalachee Parkway

Tallahassee, FL 32399- 3060

Lisa Smith, Bureau Chief MPF

Agency for Health Care Administration Deborah Kenon, MPF

E - Mail) E - Mail)

Florida Hospital Flagler, Inc. AHCA vs. Agency No.: 15- for 113) Health Care Administration

FINAL ORDER

Page 2 of 3

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been furni hed to

the above named addressees by U. S. Mail or other designated method on this theay of

2019.

Richard J. Shoop, Esquire

Agency Clerk

State of Florida

Agency for Health Care Administration

2727 Mahan Drive, MS # 3

Tallahassee, Florida 32308- 5403

850) 412- 3689/ FAX ( 850) 921- 0158

Florida Hospital Flagler, Inc. ANCA vs. Agency No.: 15- for 113) Health Care Administration

FINAL ORDER

Page 3 of 3

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

MEMORIAL HOSPITAL

FLAGLER, INC. d/ b/ a

FLORIDA HOSPITAL

FLAGLER,

Petitioner,

u AHCA CASE NO.: 15- 113

DOAH CASE NO. 15- 1666

Medicaid Provider #: 101893

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent.

SETTLEMENT AGREEMENT

Petitioner, FLORIDA HOSPITAL FLAGLER, INC. f/ d/ b/ a FLORIDA HOSPITAL

FLAGLER (" AdventHealth Palm Coast"), and Respondent, the STATE OF FLORIDA, AGENCY

FOR HEALTH CARE ADMINISTRATION (` AHCA" or " Agency"), and collectively referred to

as the " Parties," by and through the undersigned, hereby stipulate and agree as follows:

1. The Parties enter into this Agreement for the purpose of memorializing the

resolution of this matter.

2. AdventHealth Palm Coast is a Medicaid provider in the State of Florida, provider

number 101893, and was a provider during the relevant period.

3. In its Notice of Agency Action dated February 13, 2015, ( the " Notice"), the Agency

notified AdventHealth Palm Coast, in part that "... AHCA has determined that all cost reports,

desk or onsite audits of cost reports, audited per diem reimbursement rates calculated by AHCA,

or adjustments to audited per diem reimbursement rates calculated by AHCA relating to the

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 1 of 7

Medicaid inpatient and outpatient reimbursement rates identified in the Attached Exhibit A are

final' ... and therefore not subject to further re - opening or adjustment." A copy of the Notice is

attached hereto as Exhibit " A."

4. In response to the Notice, on March 13, 2015, AdventHealth Palm Coast filed a

Petition for Formal Administrative Hearing (" Petition"). A copy of the Petition ( less exhibits) is

attached hereto as Exhibit ` B." The Petition sought a determination that the Agency incorrectly

calculated AdventHealth Palm Coast' s rates for the rate semesters set forth in the Notice.

5. In order to resolve this matter without further administrative proceedings, and based

upon additional information reviewed during the pendency of litigation, AdventHealth Palm Coast

and AHCA agree with the revised rates and payments as included on the attached Exhibit " C".

AdventHealth Palm Coast agrees to promptly make payment consistent with the terms on Exhibit

C" in the total amount of $ 21, 644. 07, but no later than 90 days after the entry of the Final Order,

which shall be entered no later than 90 days after this Agreement is fully executed by the Parties.

6. As to the adjustment of any outpatient rates on Exhibit " C" that are within the past

seven years ( rate semesters beginning July 1, 2012), AHCA agrees to promptly re - process all

applicable claims using the revised rates, and the Parties agree that they are bound by such revised

rates and will make any payments or adjustments required consistent with applicable law as

required by such re - processing.

7. AdventHealth Palm Coast and AHCA agree that the revised rates as shown on

Exhibit " C" supersede the rates on Exhibit " A" and shall be final and not subject to further re-

opening or adjustment. AdventHealth Palm Coast and AHCA further agree that all other rates

appearing at Exhibit " A" shall also be final and not subject to further re - opening or adjustment.

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 2 of 7

Such finality, however, may not affect any reconciliation that AHCA may have to make as a matter

of law as a result of Medicaid Disproportionate Share Hospital ( DSH) Payments. Such finality,

however, may also not affect any adjustment to the rates resulting from any recalculation of the

Medicaid Trend Adjustment which may be required as a result of the consolidated appeals styled

Southern Baptist Hospital of Florida, et al. v. Agency for Health Care Administration ( lowest Case

No. 1 D17- 2027, Florida First District Court of Appeal).

8. The Parties otherwise agree that the above adjustments resolve and settle this case

completely and release each from any administrative or civil liabilities arising from the findings

relating to the claims of adjustment of Medicaid Inpatient and Outpatient Hospital Rates pursuant

to the Notice. Such resolution, however, shall not prevent AHCA from recovering any

overpayment that is not authorized to be paid by the Medicaid program whether paid as a result of

inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or

mistake. Further, such release shall not prevent AHCA, the United States Medicaid Fraud Control

Unit, or any other nonsignatory to this Agreement from pursuing any action relating to fraud

against AdventHealth Palm Coast.

9. This settlement does not constitute an admission of wrongdoing or error by either

party with respect to this case or any other matter.

10. The signatories to this Agreement, acting in a representative capacity, represent that

they are duly authorized to enter into this Agreement on behalf of the respective parties.

11. This Agreement shall be construed in accordance with the provisions of the laws of

Florida. The exclusive venue for any action arising from this Agreement shall be in Leon County,

Florida.

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 3 of 7

12. This Agreement constitutes the entire agreement between AdventHealth Palm

Coast and AHCA, including anyone acting for, associated with or employed by them, concerning

all matters and supersedes any prior discussions, agreements or understandings; there are no

promises, representations or agreements between AdventHealth Palm Coast and AHCA other than

as set forth herein. No modification or waiver of any provision shall be valid unless a written

amendment to the Agreement is completed and properly executed by the Parties.

13. This is an Agreement of settlement and compromise, made in recognition that the

Parties may have different or incorrect understandings, information and contentions as to facts and

law, and with each party compromising and settling any potential correctness or incorrectness of

its understandings, information and contentions as to facts and law, so that no misunderstanding

or misinformation shall be a ground for rescission hereof.

14. AdventHealth Palm Coast expressly waives in this matter its right to any hearing

pursuant to sections 120. 569 or 120. 57, Florida Statutes, the making of findings of fact and

conclusions of law by the Agency, and all further and other proceedings to which it may be entitled

by law or rules of the Agency regarding this proceeding and any and all issues raised herein.

AdventHealth Palm Coast further agrees that it shall not challenge or contest any Final Order

entered in this matter which is consistent with the terms of this Agreement in any forum now or in

the future available to it, including the right to any administrative proceeding, circuit or federal

court action or any appeal.

15. The Parties agree to bear their own attorneys fees and costs.

16. This Agreement is and shall be deemed jointly drafted and written by all Parties to

it and shall not be construed or interpreted against the party originating or preparing it.

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 4 of 7

17. To the extent that any provision of this Agreement is prohibited by law for any

reason, such provision shall be effective to the extent not so prohibited, and such prohibition shall

not affect any other provision of this Agreement; provided, however, if any provision of this

Agreement regarding the payments required herein is prohibited by law, this Agreement is null

and void and of no further effect, and AHCA agrees that it will send this appeal to DOAH for

hearing at the request of AdventHealth Palm Coast.

18. This Agreement shall inure to the benefit of and be binding on each Party' s

successors, assigns, heirs, administrators, representatives and trustees.

19. All times stated herein are of the essence of this Agreement.

20. The Parties acknowledge that AHCA' s payments required pursuant to the terms of

this Agreement are subject to and contingent upon the review and approval of the Chief Financial

Officer pursuant to his authority as set forth in the Florida Constitution and section 17. 03, Florida

Statutes, which provides in pertinent part: " The Chief Financial Officer of this state, using

generally accepted auditing procedures for testing or sampling, shall examine, audit, and settle all

accounts, claims, and demands, whatsoever, against the state, arising under any law or resolution

of the Legislature, and issue a warrant directing the payment out of the State Treasury of such

amount as he or she allows thereon." Should the Chief Financial Officer not approve such

payments, then this Agreement shall be null and void and of no further effect, and AHCA shall

immediately refer the matter to DOAH for a formal administrative hearing.

21. This Agreement shall be in full force and effect upon execution by the respective

Parties in counterpart; provided, however, if AHCA does not execute the agreement within 90 days

of execution by AdventHealth Palm Coast, such hospital may, in its sole discretion, withdraw its

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 5 of 7

acceptance of the agreement at any point thereafter.

THE REMAINDER OF THIS PAGE INTENTIONALLY BLANK

Florida Hospital Flagler, Inc. vs. Agency for Health Care Administration

AHCA Case No.: 15- 113)

Settlement Agreement

Page 6 of 7

FLORIDA HOSPITAL FLAGLER, INC.

Dated:

Providers' Representative

M.

Print name and Title)

Dated:

Legal Counsel for Provider ( as to form and sufficiency)

C

Print Name)

AGENCY FOR HEALTH CARE ADMINISTRATION

2727 Mahan Drive, Bldg. 3, Mail Stop # 3

Tallahassee, FL 32308- 5403

Dated: , 2019

Stefan R. Grow, Esquire

General Counsel

Dated: 2019

Beth Kidder

Deputy Secretary for Medicaid

uAL Dated: 6 ' 2019

Tom allace

ADS, 1 Iedicaid Firipnce 8r Analytics

Lisa. Smith y' c Dated: - 1 ' 21 , 2019

Byu Chif, e Bureau of Medicaid Program Finance

Dated: 9/- 5 . 2019

Sh VL. Grantham

CMedicaid hie Administrative Litigation and

Medicaid Program Integrity Counsel

Dated: August 6. 2019

Joseph M. Goldstein

Shutts & Bowen, AHCA Outside Counsel

Florida Hospital Flagler, Inc. ARCA vs. Agency No.: 15- for 113) Health Care Administration

Settlement Agreement

Page 7 of 7

FLORIDA HOSPITAL FLAGLER- INC

Dated:

Providers' ReFfk, entative

B Y: l (

Pani r Name dt) I IT i t I e)

x/

Dated: 07 '

Legal Vounsel fot( Tkvider ( as to form and sufficiency)

BY:

Print

AGENCY FOR HEALTH CARE ADMINISTRATION

2727 Mahan Drive. Bldg. 3, Mail Stop k3

Tallahassee. FL 32308- 5403

Stefan R. jff Gi- oxv Dated:

General Counsel

Dated

Beth Kidder

Deputy Svemtary for Mcdicald

Dated

Tom Wallace

ADS, Mydicaid Finance & Anal tics

tIL Dated:

Li wth

Bureau Chief, Medlcaid Program Finance

Dated:

Kim A. Kellum

Chief Medicaid Counscl

Dated:

Joseph M. Goldstein, Esq.

as to form and sufficiency)

Flonda Hospital Hagler, hic, %. Agency for Health Gare Administration

A I i CA ( ase No I - I l3)

ScUlcment Agreemcni

Pqc 7 of 7

Exhibit " A"

A

RICK SCOTT

GOVERNOR

ELIZABETH DUDEK

SECRETARY

February 13, 2015

Certified Mail Receipt No.:

917108 2133 3937 6303 6144

Florida Hospital - Hagler

Attn: Hospital Administrator

60 Memorial Medical Parkway ,

Palm Coast, Florida 32164

Reference( s): Notice of Agency Action

Historical Medicaid Inpatient and Outpatient Hospital Reimbursement Rates

Medicaid Provider Number 1. 01893

Dear Administrator:

Section 409. 905, Florida Statutes and Florida' s Medicaid inpatient and outpatient hospital

reimbursement plans provide, in relevant part, the following with regard to hospital cost reports

and Medicaid reimbursement rates for inpatient or outpatient hospital services:

The agency [ AHCA] may not make any adjustment to a hospital' s

reimbursement more than 5 years after a hospital Is notified of. an audited rate.

established by the agency. The prohibition against adjustments more than 5 years

after notification is remedial and applies to actions by providers involving

Medicaid claims for hospital services.

Effective October 1, 2013, for cost reports received Via to October 1. 200, all

desk or onsite audits of these cost reports shall be final and not subject to

reopening."

For cost reports received on or Alta October 1, 2003, all desk or onsite audits of

these cost reports shall be final and shall not be reopened past three years of the

date that the audit adjustments ts. are noticed through a revised per diem rate

completed by the agency.

In accordance with these provisions, AHCA has determined that all cost reports, desk or

onsite audits of cost reports, audited per diem reimbursement rates calculated by AHCA, or

adjustments to audited per diem reimbursement rates calculated by AHCA relating to the

t3 §§ 409. 905( 5)( c) 2 and ( 6)( 6) 2., Fla. Stat. ( 2013); Subsection I( M), Florida Title IX Inpatient Hospital

Reimbursement Plan, Version XXXiX, incorporated by reference in 590- 6. 020, Fla. Admin. Code

Inpatient Pian'); Subsection I( 0). Florida Title IX Outpatient Hospital Reimbursement Plan, version

XXIII, incorporated by reference In 59- 0 5. 030, Fla. Admin. Code (" Outpatient Plan').

14 Inpatient Plan § IV( H)( 3); Outpatient Plan § IV( G)( 5).

s Inpatient Plan §§ I( I), 11( F), iV( H)( 3); Outpatient Pian §§ II( F), IV( G)( 5).

Tallahassee, 2727 Mahan Drive • FL 3230a Mail Stop 23 Faoebook. Youtube. comlAHCAFlorlda com1AHCAFlorlda

AHCA. MyFloridamom SlideShare. Twitter. netlAHCAFIorida comlAHCA- FI.

Medicaid inpatient and outpatient rtamburserrentcates' identified in the attached Exhibit Aare

Final'? as that* term is used in the provisions quoted above, and therefore not subject to further re -

opening or adjustment.

The authorities. cited in this notice contain' pmvisions which under certain circumstances

authorize the : Agency to re - open, correct or adjust' historical ' cost reports - and- reimbursement

rates. 16 AHCA' s determination that the reimbursement iates identified - in Exhibit A are final is

without prejudice to, or ( imitation on,." our hospital' entitlement to submit amended cost reports

or request corrections or adjustments to reimbursement rates in accordance with, and subject to .

any limitations in, the provisions authorizing such adjustments in the authorities cited herein. If

ARCA enters an order determining the reimbursement rates identified in Exhibit A are final, that

deterinioation of finality will apply only to a reimbursement rate as currently " established and as -

reflected in Exhibit. A, and will not preclude your hospital from requesting there - opening of a

cost report or the correction or adjustment of a reimbursement rate if your hospital was entitled

to such adjustments both prior to and after the en' try - of AHCA' s order determining the finality of

the rate as currently calculated and as reflected in Exhibit A.

For audited reimbursement rateslisted in Exhibit A which- your hospital is nen currently

entitled to have re - opened uader• any other provisions set. forth in the authorities cited above, any

requests for cost report re - opening or adjustments to sach' rates 6efoie they become final as a

inatter of law : n ust ba - in the form of a request for a hearing challenging the Agency action

descniied in this notice, ' and must - be made in strict compliance with the directions in this. notice

and the enclosed Notice of Adininistrative Hearing and Mediation. Rights within twenty- one ( 2 1)

days of your receipt of this letter, or else your hospital' s opportunity to challenge this Agency

actioribefore it becomes final will be lost.

Mei Agency action/ determination - of finality described in this notice only applies to

audited reimbursement rates listed in. Exhibit A It does not apply to any rates included in Exhibit

A that are preliminary or unaudited as of the date of this notice. When final, audited

reimbursement rates arse established for any currently unaudited rate semesters included in

Exhibit A, a separate Notice of' Agm4 Action and Notice of Administrative Hearing and

Mediatiou Rights will be sent with - notice of those audited rates.

Pursuant to § 120. 57, Fla. Stat,, you have the' riglit to request a formal or informal } fearing

challenging the determinations set forth in this letter and Exhibit A to. same. It petition for a

formal hearing is made, the petition must be made in compliance with' Rule 28- 106. 201, Fla.

Admin. Code. Please note that Rule 28. 106201( 2) specifies that the petition must contain a

concise discussion 6f specific items in dispute. Additionally, you * are hereby informed that if a

request for a hearing is made, the request or petition must be received within twenty- one ( 21)

days of your receipt of this notice, and that failure to timely request a hearing shall be deemed a

waiver _ of your right . te a. heiving. . For- more Wforrnation regarding . your hearing and

mediaft6n rights, please see the enclosed Notice of Administrative Hearing and Mediation

tights - form. If you wish to request an administrative hearing, you - must carefully follow all

of the directions for" doing so set out in that form. -

is For example, Inpatient Plan 4 W( H); Gutpatfeut Plan §- 1V( G)

J

E

Sincerely, ... . .

W. Rydell Samuel

Regulatory Ancil yst Stipervisor

Medicaid Program Finance,

Enclosures:

Exhibit A

Notice of Administrative Hearing and Mediation Rights

WRSfba -

f ' Q10189300 -" MEMORIAL' HE4LTH SYSTEMS, INC` Jnpatlent 198907' 19 782-- 76

010189300 ": "` MEMORIAL HEALTH SYSTEMS, INC. Qutpatient 18890719- 120. 26

QIQ18930Q - MEMORIAL' • HEALTH SYSTEMS, INC, :.::: Inpatienf • 19891001

010184300 •.:" MEMORIAL HEALTH SYSf' EMS,' INC: ,:: - - Outpatient :. 19891001- '. 120. 26

010189360 :: MWORIAL" HEALTH SYSTEMS; INC. Inpatient ' ' 19900701 14. 02

010189300- .: MEWRIAL HEALTH SYSTEM5, INC.... triC. : „ Outpatient ..:. -: 19900701: 83. 83.

0IM893OD::'- ::: MEMORIAL HEALTH SYSTEMS, INC. ":: Inpatient ' 19910101. 830. 74

018930[ l ...... MENIORIAL, HEP LiH SYSTEMS, INC.. 7: Oatpatleht 1900101• : '" ' 83. 90

l 01. 0189300. ':::,`_ MEMORIACHFACTH SYS' T' EMS, INC: Inpatient 19910701 829. 62

010189300 •:'.` MEMORIAL HEALTH SYSTEMS, INC. ' ..::::: 1> ut; iatient 19910701: :: $ 3. 73

010189300: :.. MEMORIAL HEALTH SYSTEMS, INC.-..:: `: inpatient 19920101 • : "` 627: 11 .

020189- 3 -- MEMORIAL HEALTH SYSTEMS, INC. ::, ' Outpatient 19926101' 45. 60

010189300 : = ' MEMORIAL HEALTH SYSTEMS, ! NC.:' Inpatient 19920701: 580. 20. ]

QiQ189300 MEMOMAL HEALTH SYSTEMS, INC :;`- Outpatient: 199207. 01 39. 80 4

010189300' : MEMORIAL HEALTH SYSTEMS, INC.: ' . Inpatient 19930101 5$ 6. 7q

010189300 ;: -:: MEMORIAL HEALTH SYSTEMS; INC.:: =.`•' ' _: Outpafient _ 19930101 ' 40, 37

010189300 .. MEMORIAL HEALTH 5YSIEMS, INC.: Inpatien) :. 19980701 660. 17

010189300, : MEMORIAL HEALTH SYSTEMS, INC T dtifpatient 19930701 50. 22

010189300 MEMORIAL HEALTH SYSTEMS, INC.* Inpatienti 19940101 663. 74-

010189300.' : .; MEMORIAL HEALTH SYSTEMS, Ifi[ C.. .:. ;:' putpatient .: 19940101

010189300 - MEMORIAL HEALTH SYSTEMS, INC ` . -._ inpatlent . - 19940701 870, 60

i 010189300 . •. MEMORIAL HEALTH SYSTEMS, INC.:' Outpatient .. 19944701 51. 18

010169300 MEMORIAL HEALTH SYSTEMS;' ING Outpaoenty Inpatient 19950107 780. 67

010189300 fr4Ef, AORIAL HEALTH SYSTEMS; INC 19950101 52. 18:

j 010189300 ::::-:. MEMORIAL HEALTH SYSTEMS,, ING,. inp ea rtti t 19950701 729. 78

010189300 ' - MEMORIAL HEALTH SySTEfyIS, INC. Qu atlent - 19950701 48. 15

0]. 0189300 MEMORIAL HEALTH SYSTEMS, ING- inpatient 19960101 736. 92

0_ 10189300_ T, MEMORIAL HEALTH SYSTEMS, INC.' Outpatient r 19960101 48. 76 1

010189300 MEMORIAL HEALTH SYSTEMS, INC. Inpatient 19960701 744. 85

010189300 MEMORIAL• HEALTH SYSTEMS, INC. Outpatlent 19960701. 49. 44

010189300. MEMORIAL HEALTH SYSTEMS, INC. " Inpatient- 19970101: 752. 00 ,

010189300 MEMORIAL HEALTH SYSTEMS, INC.•:::- Outpatient- 19970701 :_ 50. 05

010189300 MENfORIAL HEALTH SYSTEMS, INC. Inpatient 19970701 921. 80

610189300 MEMORIAL HEALTH SYSTEMS, INC.,' Outpatierrt 19970701 ' 55. 14

o101893( J0 MEMORIAL HEALTH SYSTEMS, INC. :- . Inpatlent 19980101 925. 44

410189300 - MEMORIAL HEALTH SYSTEMS, INC. ': Out ' anent 19980101: 55. 40

l 0101 9300 MEMORIAL - HEALTH SYSTEMS, INC. ' : Inpatient 19980701 856. 76

s 01- 01 ~ MEMORIAL HEALTH SYSTEMS, INC: • Outpatient 19980701: 0. 07

0101893DO MEMORIAL HEALTH SYSTEMS, INC. '• Inp dent 199911101 864. 15

0101893 Y- MEMORIAL HEALTH SYSTEMS, INC.`' .. Outpatient_ 19990101 -. 50. 58

tXhibit A

010189300. MEMORIAL HEAvn4 SYSTEMS, INC:. Inpatient 199907111 874. 05 J

010I893DD - MEMORIAL HEALTH SYSTEMS, INC, putpatletit: 19990701- 51. 27 j

6101. 89300. MEMOitiAL HEALTH SYSTEMS, INC.- Inpatient :': 2000610') 87. 57.

610189300 MEMORIAL FIEAtiFi SYSTEMS, INC. ' Outpatient• 20DO0101- 52. 20 f

010189300. MEMORIAL HEALTH SYSTEMS; iNC..: Inpatient 20000701 954.. 664

1 .. 010189300 MEMORIACHEALTH SYSTEMS, INC.' :. Outpatient 20000701 -- 53. 89 ,

010189300.. MEMORIAL HEALTH SYSTENIS,' INC. Inpatient . ' - 20010101 -: 96$. 10

010189300 MEMORIAL HEALTH SYSTEMS INC. - Outpatient 2001 D101 - 54: 73

010189300 1 1EMQRiAL HEALTH SYSTEMS, ING .. In A atient - 20010701 926. 90 t

010189300 -:-..'., MEMORIAL HEALTH SYSTEMS, INC..:. • : Outpatient' . 20010701 52- 84

OIU]. 89300- - :: MEMORIAL HEALTH SYSTEMS; INC ._:: Inpatlent..• '. 20020101 944. 38

0I0189300 MEMORIAL HEALTH SYSTEMS, INC outpatient :: 20020101 v 3. 8. 1

1 ' 010189300 .. MEMORIAL HEALTH SYSTEMS, INC.:. v -- Inpatient:: 20020401: 1, 004. 66 ;

01018930b : MEI OMAL HEALTH SYSTEMS, ING :.: Outpatient ;: 20020401` 57. 25 I

010189300' MEMOR[ A:- ZVH SYSTEMS, INC. '• Inpatient. 20020701 . 1, 023. 26'

010189300:. MEMORIAI. HEALTH SY5' iI M5, 1NC `' Outpatient ' ' 20020701 56. 50

1'": 0101893010'-,_ MEMORIAL: HEALTH SYSTEMS, INC._ '' .;... Outpatient 20030101- 68. 57

OI0189300 MEIVIORIAL. HEALTHSPSTEMS, INCA : lnpatlerrt . 20 030461 1; 21$. 94

I 910189300 MEMORIACHEALTH SY57EMS,' iNC - [ npatlenE' !_ 20031001 1, 184. 29

I: 010189300.: MEMORIAL' HEALTH SYSTEMS, INC ' ..: Outpatient 20031001 = 72, 75.:

010189300 MEMORIAL HEALTH SYSTEMS, INC: ' :.;.:. • Inpatient 20040101. 1, 329, 95•

010189300-- MEMORIAL HEALTH• SYSTEMS, INC, -:. - Outpatient 20040/ 01 .' 74. 1[ 0 ,

r . • 010I89300. MEMORIAL HEALTH SYSTEMS, INC, Inpatient -'- 20040701 1; 348. 25

03. 0189300 MEMORIAL HEALTH SYSTEMS, INC ` Outpatient 20040701 72. 94

010189300..., :. MEMORIAL HEALTH SYSTEMS; INC.. '° - 160atlent 20050101 - 1. 550 1

010189300 .- MEMORIAL HEALTH SYSTEMS, ING ' ; ; O' utpatierit 2U0501D1 78. 21

O10i89300-• MEMORIAL HEALTH SYSftMS, INC: Inpatient 20050701 1, 056. 50

I, 01Q189300., MEMORIAL HEALTH SYSTEMS, INC. Outpatient 20050701 81. 4915

016189300. MEMORIAL- HEALTH SYMMS, [ NG :` Iripatlent 20060101- 1, 056. 50';

OIQ189300 . MEMORIAL HEALTH SYSTEMS, INC: Outpatient .: - 20060101: 18: . 4fi

g1M' 8930- 0 MEMORIAL HEALTH SYSTEMS, INC. Inpatient- - 20. 060701• 1, 375. 43

010189300 MEM091AL HEALTH SYSTEMS, INC Oritpatient ' 20060701 81. 26

010189300 - MEMORIALHEALTH SYST MS, ING. Inpatlent 20070101. i, 3a 5151

010189300* MEMORIAL HEALTH SYSTEMS, INC... Outpatient- 20070101 72. 4' 1:

010189300 MEMORIAL HEALTH' SYSTEMS, INC. fnpatlent 20070701 1, 309. 51- 1

016189300' MEMORIAL HEALTH SYSTEMS, INC.: Outpatient 20070701' 72. 37'•

010189300 .- MEMORIAL HEALTFI SYSTEMS, INC: Inpatient 20080101 1, 265. 84

i 010189360 MEMORIAL HEALTH SYSTEMS, INC Outpatient 20080101. 62. 34'

010189300' MEMORIAL HEALTH SYSTEMS, INC:_ Inpa 20080701 1' 26 97

j 010189300 MEMORIAL HEALTH SYSTEMS, INC Outpatient • 20080701 82. 01'

010189300 ` MEMORIAL: HEALTH SYSTEMS, INC. Iripatlent- 20090101 i 350. 76

C

Exhibit A

t rt tea.{ f s _ s - f• i= z.' 2` a `} i

U - f2i ,

LKIr 7 s r -. r' 7 y x4- .. r 3 - , r y , Y 3., t' fS• f'' r 3 .. r s, x - ta. i c :.'` 1 ` -• o _

s• Z

1YtCL r- Ft"` Yn. T4[ p}} F. a 7Yj r'' rr i c y... F L . . arrS. v`. as. f` i•`' WYlL SCT'. } 3s" y aX Y- r}_ T. g" j; _ a, f.{ G2 F r..}. 3H• yti". f-. }'_ f• r.« }-{` HyLtik. tLr' t'.. Y s

63. 98 ' =

1-, 295. 75

010189300-- MEMORiAL HEALTH SYSTEMS, INC. Dtoaffent 2009D301'. 61. 22

1 1 :' tr J 11. 1 t 1, 420. 41

Mr- IAMTIAZMI Me. MAMILM, MOM 65. 88 l

1, 511 3 ss

1 1 :• fl 1 It t 67. 93

i I1 1, 536. 44 !

P3 V" M 60. 08

1, 619. 701,/

75. 02-

r. 010189300 :: MEMORIAL HEARTH SYSTEMS, INC. Inpatient 20110701. 5, 615. 48 /

r 010189300 '.' MEMORIAI• HEAL i H SYSTEMS,, NC. ' Dutpatlent Dutpatlent 20110701 20110701 73: 73: 96 % 96 %

010189300 :_:: 010189300 :_:: MEMORIAL MEMORIAL HEALTH HEALTH SYSTEMS, SYSTEMS, INC.- :.:• =::. INC.- :.:• =::. lcipatient lcipatient 20120701- 20120701- 1, 683. 34 pe

01018930Q : MEMORIAL HEAITIH SYSTEMS, INC. Outpatient 20120701

0101893QQ = ' NfEMDRtAL NfEMDRtAL HEALTH HEALTH SYSTEMS, SYSTEMS, INC.: INC.: Outpatient 20130701 86. 86. 32 32 j j J J

Lvr" {.

rC{' ' Jf.

t6 Tp

J

r CAk

RICK SCOTT

GOVERNOR

ELIZABETH DUDEK

SECRETARY

NOTICE OF ADMMSTRATIVE HEARING

AND MEDUTION RIGHTS

You have the fight to' request an administrative hearing pursuant to Sections 120. 569 and

120. 57, Florida Statutes.' if you disagree with the facts stated in the enclosed Notice of Agency

Action, you may request a formal administrative hearing pursuant to Section 120. 57( 1), Florida

Statutes. If you do not dispute the facts stated in the Notice of Agency Action, but believe there

Are additional reasons to grant the relief you seek, you may request as informal administrative

hearing pursuant to Section 120. 57( 2); Florida Statutes. - Additionally, pursuant. to Section

120. 573, Florida Statutes, mediation may be available if you have chosen a formal administrative

hearing, as discussed more failybelow.

Your written request for an administrative heanng must conform to the requirements of

either Rule 29406. 201( 2) or Rule 28- 106. 301( 2), Florida Administrative Code, and must be

received by the - Agency Clerk for - the Agency for Health Care Administration, by 5: 00 P. 1vt no

later than 2 1 - days after the day you received the Notice of Agency Action. The address for filing

the written " request for an administrative hearing is:

Richard J. Shoap,. Esquire

AgencyClerk

Agency for Health Care AdminiAration

2727 Mahan Drive; Mail Stop # 3

Tallahassee, Florida 32308

Fax: -( 850) 921- 01%

T` e; request rriust be legiirle, on 8' l: by 114neh white. paper, and contain: '

1. Your name; address, telephone number, any Agency identifying number on the Motto of

Agency Action, if known, and name, address, actd telephone number of your

representative, if any;

2. An explanation of how your substantial interests will be affected by the action described

io the Notice of Agency Action;

3. A statement bf when and how you received the Notice of Agency Action;

4. For a request for formal hearing, a statement of all disputed issues of material fact;

5: For a request for formal hearing, - a concise statement of the ultimate facts alleged, as well

as the rules and statutes which entitle you to relief;

6. For a request for formal hearing, whether you request mediation, if it is available;

7. For a request for informal hearing, what bases support an adjustment to the a fount owed

to the Agency,. and

9. A demand for relief. -

A formal hearing will be held if there are disputed issues of material fact. Additionally,

mediation may be available in conjunction with a formal - hearing: Mediation. is a way to use a

neutral ' third party to assist the parties in a legal or administrative proceeding to reach. a

settlement of their case. If you and the Agency agree to mediation, it does not mean that you -

give up the right to a lieiring. Rather, you and the Agency will try to settle your case first. with

mediation.

2727 Vahan ' Drive •! Ball Stop 23 Fa" Youluba. hook. com1AHCAFIorlde cam/ AHCAFIorlda

TbIlahassee, FL 32308 Twitter. com/ AHCA FL

AHCA. MyFlorlda. coli SltdeShare. nal/ AHCAFIor_ ida

If you request mediation and the Agency agrees to it, you• will tie $ ontacted by the

Agency to, set up a time * for. the mediation and to enter lutes a* mediation agreement.. If a

mediation agreement is not ruched within 10 hays following. therequest for mediation, the

matter will. proceed without mediation. The mediation must• be concluded within. 60 days of

having entered into the agreement, unless you and Me. Agency agree to a differcut time

period,- The `` mediation agreement between you and the Agency will. include provisions for

selecting the mediator, the allocation of costs and fees associated VM the mediation, Mediators' and. - charge the

cairfidentiality of discussions and documents involved in the mediation.

hourly fees that imust be shared equally by . you and the Agency,

If a written request for an adminisfra6ve hearing is not timely received you will have - waived ... _

your right to have the intended acfion reviewed pursuant to Chapter 120, Florida Statutes, and

the action set forth in the Notice of Agency Action shall be conclusive and final.

Exhibit " B"

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

AGENrc_ y C1, r, r2r

MEMORIAL HOSPITAL MAR I `? 015

FLAGLER, INC. d/ b/ a

FLORIDA HOSPITAL Agency fbi• rfc; tl/ f

FLAGLER, Car" Adrll ir istrli tia3

Petitioner,

V. AHCA Case No.:

Medicaid Provider /#: 101893

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent.

PETITION FOR FORMAL ADMINISTRATIVE HEARING

Petitioner, MEMORIAL HOSPITAL FLAGLER, INC. d/ b/ a FLORIDA HOSPITAL

FLAGLER (" Florida Hospital Flagler"), by and through its undersigned counsel, and pursuant to

Sections 120. 569 and 120. 57( 1), Florida Statutes, and Rule 28- 106. 201, Florida Administrative

Code, hereby requests a formal administrative hearing regarding Respondent Agency for Health

Care Administration' s " Notice of Agency Action: Historical Medicaid Inpatient and Outpatient

Hospital Reimbursement Rates" dated February 13, 2015. In support of this Petition, Petitioner

states as follows:

1. For the purpose of this Petition, Petitioner' s name, address and telephone number

is Florida Hospital Flagler, Reimbursement Services, 900 Hope Way, Altamonte Springs, Florida

32714, 407- 357- 2315. The name, address, telephone number, facsimile number and e- mail

address of the attorneys for Petitioner upon whom service of pleadings and other papers should

be made is provided in the signature block below.

I

2. The name and address of Respondent is STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRTATION ( hereinafter " Agency" or " ARCA"), 2727 Mahan

Drive, Mail Stop 43, Tallahassee, Florida 32308. The agency action at issue in this proceeding is

a letter dated February 13, 2015, entitled " Notice of Agency Action: Historical Medicaid

Inpatient and Outpatient Hospital Reimbursement Rates" ( hereinafter " Notice"). A copy of the

Notice is attached hereto as Exhibit " 1." The Agency' s file or identification number is not

known.

3. The Petitioner' s Medicaid Provider Number is 101893. Petitioner received the

Notice via certified mail on February 20, 2015, and this Petition for Formal Administrative

Hearing is timely filed within twenty- one ( 21) days from receipt of the Notice.

4. Florida Hospital Flagler is a hospital located in Palm Coast, Florida, which

participates in the Florida Medicaid Program administered by the Respondent. The Agency' s

Notice states, in pertinent part, that "... AHCA has determined that all cost reports, desk or

onsite audits of cost reports, audited per diem reimbursement rates calculated by AHCA, or

adjustments to audited per diem reimbursement rates calculated by AHCA relating to the

Medicaid inpatient and outpatient reimbursement rates identified in the Attached Exhibit A are

final' ... and therefore not subject to further re - opening or adjustment." Exhibit 1, pgs. 1 and 2.

5. The Agency included as an attachment to the Notice a three page document

identified as Exhibit A therein and referenced herein above, consisting of a list of the Medicaid

inpatient and outpatient reimbursement rates which are the subject of the Notice ( hereinafter,

Exhibit A"). For Petitioner, the list includes reimbursement rates going back as far as 1989, a

total of almost 100 different rates spanning a cumulative total of more than twenty years.

6. The process for determining Medicaid reimbursement rates involves the filing by

the hospital of a cost report, which is subject to audit. The Medicaid reimbursement rates are

also the result of an audit process.

7. The procedures to be utilized to determine the Medicaid reimbursement rates for

hospitals providing inpatient services or outpatient services to eligible Medicaid recipients are

established by Section 409. 905, Florida Statutes ( 2014), Rule 59G- 6. 020, Florida Administrative

Code, Rule 59 G- 6. 030, Florida Administrative Code, the Florida Title IX Inpatient Hospital

Reimbursement Plan, and the Florida Title IX Outpatient Hospital Reimbursement Plan ( the

latter two documents have been incorporated by reference into Florida rules). Generally

speaking, the Agency over the years has established a Medicaid inpatient hospital reimbursement

rate and a Medicaid outpatient hospital reimbursement rate for a given rate semester ( which from

1984 through 2011 was for a six month period, and after 2011 is for a twelve month period), and

uses the applicable hospital specific reimbursement rates to determine the payments due to the

hospital for providing services to Medicaid eligible patients during the relevant rate semester.

8. The general purpose of the Agency Notice appears to be to " clean up" and render

final the Medicaid hospital inpatient and outpatient reimbursement rates for Petitioner for the

past twenty years. Although this is a laudable goal with which Petitioner agrees in principle, in

practice AHCA has, with little warning, required that Petitioner must file a Petition for

Administrative Hearing if it seeks to retain or exercise its rights to question the finality of any of

the almost one hundred reimbursement rates potentially becoming " final" under the provisions of

the Notice.

9. The listed Medicaid reimbursement rates included in Exhibit A of the Notice

constitute all of the reimbursement rates established by AHCA for Petitioner going back to 1989,

through and including 2013. AHCA has not, in Exhibit A, specified the status of any of these

individual rates, and has apparently commingled reimbursement rates both audited and

unaudited, as well as rates which may have been audited but which have not been utilized to

process Medicaid claims, which would be the final step of the rate setting process necessary to

bring to full closure the reimbursement due for the period of the reimbursement rate' s

applicability. The Agency' s Notice is deficient in not clearly providing Petitioner with adequate

notice as to which Medicaid rates are impacted in which ways by the Notice, and by including

reimbursement rates which should not be subject to final Agency Action.

10. Petitioner' s interests will be substantially and adversely affected if the action

contained in the Notice were to become final, and if its rights to challenge the fmality of each of

the rates identified in the Agency' s Exhibit A were thereby eliminated, lessened or

compromised. The Medicaid reimbursement rates listed in Exhibit A are the rates at which

AHCA will reimburse Petitioner for services provided to Medicaid eligible patients and the

establishment of the final rates thus substantially affects Petitioner.

11. The disputed issues of material fact raised by this Petition include the following:

A. What the status is of each individual Medicaid reimbursement rate

contained in Exhibit A.

B. Whether each of the rates contained in Exhibit A have been audited.

C. Whether any requests for reopening or other challenges to each rate

contained in Exhibit A have been filed and are pending.

D. Whether each individual rate contained in Exhibit A is unaudited.

E. Whether each individual rate contained in Exhibit A has been utilized by

ARCA or its contractors to process all relevant claims for the applicable rate semester.

F. Whether each individual rate contained in Exhibit A is, has been, or

should be considered final and not subject to further reopening or other proceedings.

G. Whether for each individual rate contained in Exhibit A, AHCA or its

agents or contractors have completed all necessary steps to result in each rate being final,

including the processing or reprocessing of all claims under each reimbursement rate.

12. The ultimate facts alleged by Petitioner are that many of the reimbursement rates

contained in Exhibit A to the Agency Notice are not and should not be deemed " final," and that

the Agency must determine which of the rates should be declared " final," and which should still

be open for determining payments, reopening, or other adjustments.

13. The statutes and rules entitling Petitioner to relief include Sections 120. 569,

120. 57( 1), and 409. 905, Florida Statutes, Rules 59G- 6. 020, 59G- 6. 030, and Rule Chapters 28-

106 and 59A- 7, Florida Administrative Code, the Florida Title IX Inpatient Hospital

Reimbursement Plan and the Florida Title IX Outpatient Hospital Reimbursement Plan. These

statutes and rules require Respondent, now and in the future, to make adjustments to all of the

Petitioner' s unaudited reimbursement rates, as well as rates which may have been audited but

which have not been utilized to process Medicaid claims, and preclude Respondent from making

final all rates set forth in Exhibit A.

14. The ultimate relief sought by Petitioner is the withdrawal of the Agency' s Notice

and the issuance of an updated Notice which declares " Final" only those rates determined by this

proceeding or agreement between the parties to be final under relevant law.

15. Petitioner is willing to participate in mediation of the issues herein presented.

WHEREFORE, Petitioner requests the following relief.- elief:

A. A. That the Agency accept Petitioner' s Petition for Formal Administrative

Hearing and transmit the Petition to the Division of Administrative Hearings for the conduct of a

formal hearing;

B. That the Administrative Law Judge enter a Recommended Order

recommending that the Agency' s Notice be withdrawn;

C. That the Agency issue a Final Order withdrawing its Notice; and

D. That all other relief be granted as is appropriate under the circumstances.

Respectfully submitted this 13th day of March, 2015.

STEVEN T. MINDLIN, P. A.

Fla. Bar # 378534

smindlin@sfflaw. com

KYLE L. KEMPER, ESQ.

Fla. Bar # 628069

kkemper@sfflaw. com

SUNDSTROM & MINDLIN, LLP

2548 Blairstone Pines Drive

Tallahassee, Florida 32301

Telephone: ( 850) 877- 6555

Facsimile: ( 850) 656- 4029

Attorneys for Florida Hospital Flagler

on

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that the original and one copy of the foregoing has been served by

Hand Delivery to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive,

Tallahassee, Florida 32308 and a true and correct copy of the foregoing has been served by Hand

Delivery to Don Freeman, Esquire, AHCA General Counsel' s Office, Agency for Health Care

Administration, 2727 Mahan Drive, Tallahassee, Florida 32308 on this 13th day of March, 2015.

STEVEN T. MINDLIN, P. A.

Exhibit " C"

Florida Agency For Health Care Administration 101893 - 2008/ 01

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2006

Audit Status: Field Audit

Provider Tvoe:

HOSPITAL Current Rate New Rate Effective Date

Inpatient 1265. 84 1261. 20 1/ 1/ 2008

Outpatient 62. 34 63. 02 1/ 11/ 2008

Inpatient County Billing Rate 1/ 1/ 2008

Interim X Prospective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

Florida Agency For Health Care Administration 101893 - 2008/ 07

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2006

Audit Status: Field Audit

Provider TVDe:

HOSPITAL Current Rate New Rate Effective Date

Inpatient 1226. 97 1222. 46 7/ 1/ 2008

Outpatient 62. 01 62. 69 7/ 11/ 2008

Inpatient County Billing Rate 7/ 11/ 2008

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

Florida Agency For Health Care Administration 101893 - 2011/ 01

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2009

Audit Status: Field Audit

Provider TVDe:

HOSPITAL Current Rate New Rate Effective Date

Inpatient 1619. 70 1615. 07 1/ 1/ 2011

Outpatient 75. 02 75. 03 1/ 1/ 2011

Inpatient County Billing Rate 1/ 1/ 2011

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

Florida Agency For Health Care Administration 101893 - 2011/ 07

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2009

Audit Status: Field Audit

Provider Tvae:

HOSPITAL Current Rate New Rate Effective Date

Inpatient 1615. 48 1610. 96 7/ 11/ 20111

Outpatient 73. 96 73. 97 7/ 11/ 20111

Inpatient County Billing Rate 7/ 11/ 20111

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

Florida Agency For Health Care Administration 101893 - 2012/ 07

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2010

Audit Status: Field Audit

Provider Tvne:

HOSPITAL Current Rate New Rate Effective Date

Inpatient 1683. 34 1671. 07 7/ 1/ 2012

Outpatient 82. 30 83. 46 7/ 1/ 2012

Inpatient County Billing Rate 7/ 1/ 2012

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

Florida Agency For Health Care Administration 101893 - 2013/ 07

Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive Mail Stop 23 Tallahassee, Florida 32308

Medicaid Reimbursement Rate Change Form

Florida Hospital Flagler Provider Number: 0101893- 00

60 Memorial Medical Pkwy Date: 6/ 19/ 2017

Palm Coast, FL 32164 - Fiscal Year End: 12/ 31/ 2011

Audit Status: Field Audit

Provider TVDe:

HOSPITAL Current Rate New Rate Effective Date

Inpatient DRG DRG 7/ 1/ 2013

Outpatient 86. 32 86. 72 7/ 11/ 2013

Inpatient County Billing Rate 7/ 1/ 2013

Interim X Prolective

Total Interim X Total Prospective

Settlement Based on Cost

BASIS:

Budget

Unaudited Costs

X Field Audited Costs

Revised Field Audit

Cost Report Late Test

W. Rydell Samuel or Jesse Bottcher ' tr

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Batch ID: MBX9Y Printed on : 6/ 20/ 2017 9: 42 AM

R. Florida Agency for Health Care Administration 101893 - 101893 - 2008/ 2008/ 01 01

Office of Medicaid Cost Reimbursement Planning and Finance 1261. 1261. 20 / 20 / 63. 63. 02 02

Computation of Hospital Prospective Payment Rates

For Rate Semester January 01, 2008 through June 30, 2008

Type of Control: Nonprofit ( Church) Florida Florida Hospital Hospital Flagler Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2006 - 12/ 31/ 2006 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Tyne of Cost / Charges Inpatient ( A) Outpatient ( B) Inpatient ( Inpatient ( C) C) Outpatient ( Outpatient ( D) D) Statistics ( Statistics ( E) E)

1. Ancillary 15, 865, 334. 00 17, 672, 656. 00 418, 418, 395. 395. 00 00 915, 915, 793. 793. 00 00 Total Bed Days 29, 29, 565 565

2. Routine 9, 108, 457. 00 237, 237, 629. 629. 00 00 Total Inpatient Days 23, 133

3. Special Care 4, 553, 148. 00 129, 129, 714. 714. 00 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 0. 00 00 Medicaid Inpatient Days 637

5. Intern - Resident 0. 00 0. 0. 00 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 12, 182

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Prospective Inflation Factor 1. 1. 1. 0653634698 0653634698 0653634698

8. Adjustments 0. 001 0. 00 0. 0. 00 00 0. 0. 00 00 Medicaid Paid Claims 14, 920

9. Total Cost 29, 526, 939. 00 17, 672, 656. 00 785, 785, 738. 738. 00 00 915, 915, 793. 793. 00 00 Property Rate Allowance 1. 1. 00 00

10. Charges 125, 090, 981. 00 104, 453, 485. 00 3, 3, 189, 189, 085. 085. 00 00 5, 5, 578, 578, 278. 278. 00 00 First Rate Semester in Effect 2008/ 01

11. Fixed Costs 4, 447, 152. 00 113, 113, 376. 376. 25 25 Last Rate Semester in Effect 2008/ 07

Ceiling Ceiling and and Target Target Information Information

IP ! F) OP ( F) PUG OP fGI Inflation / FPLI Data ( H)

1. Normalized Rate 1, 189. 95 69. 20 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 1. 7440

2. Base Rate Semester 2007/ 01 2007/ 07 Variable Cost Base 1, 155. 77 72. 37 Cost Report DRI Index 1. 6370

3. Ultimate Base Rate Semester 1991/ 01 1993/ 01 State Ceiling 1, 447. 50 159. 94 FPLI Year Used 2005

4. Rate of Increase ( Year/ Sem.) I 1. 024473 1. 025336 County Ceiling 1, 367. 89 151. 14 FPLI 0. 9450

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) 785, 738. 00 915, 793. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) 113, 376. 25

AD Total Medicaid Variable Operating Cost = ( AA - AB) 672, 361. 75 915, 793. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 716, 309. 65 975, 652. 41

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 637 14, 920

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 1, 124. 50 65. 39

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 1, 124. 50 65. 39

AJ County Rate Ceiling = State Ceiling ( 70% IP & 80% OP) x FPLI ( 0. 9450) for Flagler ( 18) Exempt Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 1, 124. 50 65. 39

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9 177. 98

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 1, 302. 49 65. 39

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 3, 189, 085. 00 5, 578, 278. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 5, 006. 41 373. 88

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 5, 333. 65 398. 32

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 1, 302. 49 65. 39

AU Medicaid Trend Adjustment ( IP%: 3. 1704 %, OP%: 3. 6284 %) 41. 29) 2. 37)

AV

AW

AX

AY Final Prospective Rates 1, 261. 201 63. 02

Batch ID: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Florida Agency for Health Care Administration 101893 - 101893 - 2008/ 2008/ 07 07

Office of Medicaid Cost Reimbursement Planning and Finance 1222. 1222. 46 / 46 / 62. 62. 69 69

Computation of Hospital Prospective Payment Rates

For Rate Semester July 01, 2008 through December 31, 2008

Type of Control: Nonprofit ( Church) Florida Hospital Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2006 - 12/ 31/ 2006 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Type of Cost / Charges Inpatient ( A) Outpatient ( B) Inpatient ( Inpatient ( C) C) Outpatient ( Outpatient ( D) D) Statistics ( Statistics ( E) E)

1. Ancillary 15, 865, 334. 00 17, 672, 656. 00 418, 418, 395. 395. 00 00 915, 915, 793. 793. 00 00 Total Bed Days 29, 29, 565 565

2. Routine 9, 108, 457. 00 237, 237, 629. 629. 00 00 Total Inpatient Days 23, 133

3. Special Care 4, 553, 148. 00 129, 129, 714. 714. 00 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 0. 00 00 Medicaid Inpatient Days 637

5. Intern - Resident 0. 00 0. 0. 00 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 12, 182

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Prospective Inflation Factor 1. 1. 1. 0900183711 0900183711 0900183711

8. Adjustments 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Medicaid Paid Claims 14, 920

9. Total Cost 29, 526, 939. 00 17, 672, 656. 00 785, 785, 738. 738. 00 00 915, 915, 793. 793. 00 00 Property Rate Allowance 1. 1. 00 00

10. Charges 125, 090, 981. 00 104, 453, 485. 00 3, 3, 189, 189, 085. 085. 00 00 5, 5, 578, 578, 278. 278. 00 00 First Rate Semester in Effect 2008/ 01

11. Fixed Costs 4, 447, 152. 00 113, 113, 376. 376. 25 25 Last Rate Semester in Effect 2008/ 07

Ceiling Ceiling and and Target Target Information Information

IP ( F1 OP ( F) 1P UG OP ( G) Inflation / FPLI Data ( H)

1. Normalized Rate 1, 214. 28 70. 61 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 1. 7800

2. Base Rate Semester 2008/ 01 2008/ 01 Variable Cost Base 1, 124. 50 65. 39 Cost Report DRI Index 1. 6330

3. Ultimate Base Rate Semester 1991/ 01 1993/ 01 State Ceiling 1, 521. 17 174. 17 FPLI Year Used 2006

4. Rate of Increase ( Year/ Sem.) 1. 019699 1. 019943 County Ceiling 1, 441. 31 165. 03 FPLI 0. 9475

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) 785, 738. 00 915, 793. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) 113, 376. 25

AD Total Medicaid Variable Operating Cost = ( AA - AB) 672, 361. 75 915, 793. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 732, 886. 66 998, 231. 19

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 637 14, 920

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 1, 150. 53 66. 91

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 1, 150. 53 66. 91

AJ County Rate Ceiling = State Ceiling ( 70% IF & 80% OP) x FPLI ( 0. 9475) for Flagler ( 18) Exempt Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 1, 150. 53 66. 91

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9 177. 98

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 1, 328. 51 66. 91

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 3, 189, 085. 00 5, 578, 278. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 5, 006. 41 373. 88

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 5, 457. 08 407. 54

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 1, 328. 51 66. 91

AU Medicaid Trend Adjustment ( IP%: 7. 9829 %, OP%: 6. 2948 %) 106. 05) 4. 21)

AV

AW

AX

AY Final Prospective Rates 1, 222. 461 62. 69

Batch ID: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Florida Agency for Health Care Administration 101893 - 101893 - 2011/ 2011/ 01 01

Office of Medicaid Cost Reimbursement Planning and Finance 1615. 1615. 07 / 07 / 75. 75. 03 03

Computation of Hospital Prospective Payment Rates

For Rate Semester January 01, 2011 through June 30, 2011

Type of Control: Nonprofit ( Church) Florida Hospital Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2009 - 12/ 31/ 2009 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Type of Cost / Charges Inpatient ( A) Outpatient ( B) a a atient ( atient ( C) C) Outpatient ( Outpatient ( D) D) Statistics ( Statistics ( E) E)

1. Ancillary 20, 704, 234. 00 32, 834, 971. 00 1, 1, 339, 339, 332. 332. 00 00 2, 2, 167, 167, 116. 116. 00 00 Total Bed Days 29, 29, 565 565

2. Routine 14, 503, 448. 00 877, 877, 566. 566. 00 00 Total Inpatient Days 25, 827

3. Special Care 5, 371, 280. 00 328, 328, 083. 083. 00 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 0. 00 00 Medicaid Inpatient Days 1, 644

5. Intern - Resident 0. 00 0. 0. 00 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 13, 258

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Prospective Inflation Factor 1. 1. 0636766334 0636766334

8. Adjustments 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Medicaid Paid Claims 30, 722

9. Total Cost 40, 578, 962. 00 32, 834, 971. 00 2, 2, 544, 544, 981. 981. 00 00 2, 2, 167, 167, 116. 116. 00 00 Property Rate Allowance 1. 1. 1. 00 00 00

10. Charges 170, 427, 002. 00 172, 668, 128. 00 10, 10, 114, 114, 056. 056. 00 00 15, 15, 511, 511, 438. 438. 00 00 First Rate Semester in Effect 2011/ 2011/ 01 01

11. Fixed Costs 7, 671, 457. 00 455, 455, 265. 265. 57 57 Last Last Rate Rate Semester Semester in in Effect Effect 2011/ 07

Ceiling Ceiling and and Target Target Information Information

IP ( F) QP - UF IP ( G) 02 - UG Inflation / FPLI Data ( H)

1. Normalized Rate 1, 444. 97 80. 19 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 1. 9210

2. Base Rate Semester 2010/ 01 2010/ 2010/ 07 07 Variable Cost Base 1, 139. 98 69. 08 Cost Report DRI Index 1. 8060

3. Ultimate Base Rate Semester 1991/ 1991/ 01 01 1993/ 01 State Ceiling 1, 675. 84 222. 43 FPLI Year Used 2008

4. 4. Rate Rate of of Increase ( Increase ( Year/ Year/ Sem.) Sem.) 1 1 1. 0119691 1. 017712 County Ceiling 1, 568. 08 208. 13 FPLI 0. 9357

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) 2, 544, 981. 00 2, 167, 116. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) 455, 265. 57

AD Total Medicaid Variable Operating Cost = ( AA - AB) 2, 089, 715. 43 2, 167, 116. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 2, 222, 781. 48 2, 305, 110. 65

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 1, 644 30, 722

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 1, 352. 06 75. 03

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 1, 352. 06 75. 03

AJ County Rate Ceiling = State Ceiling ( 70% IP & 80% OP) x FPLI ( 0. 9357) for Flagler ( 18) Exempt Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 1, 352. 06 75. 03

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9 276. 93

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 1, 628. 98 75. 03

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 10, 114, 056. 00 15, 511, 438. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 6, 152. 10 504. 90

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 6, 543. 85 537. 05

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 1, 628. 98 75. 03

AU Medicaid Trend Adjustment ( IP%: 0. 8540 %, OP%: 0. 0000 %) 13. 91) 0. 00

AV

AW

AX

AY Final Prospective Rates 1, 615. 071 75. 03

Batch ID: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Florida Agency for Health Care Administration 101893 - 101893 - 2011/ 2011/ 07 07

Office of Medicaid Cost Reimbursement Planning and Finance 1610. 1610. 96 / 96 / 73. 73. 97 97

Ap Computation of Hospital Prospective Payment Rates

we For Rate Semester July 01, 2011 through December 31, 2011

Type of Control: Nonprofit ( Church) Florida Hospital Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2009 - 12/ 31/ 2009 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Type of Cost / Charges Inpatient ( A) Outpatient ( B) Inpatient ( Inpatient ( C) C) Outpatient ( Outpatient ( D) D) Statistics ( Statistics ( E) E)

1. Ancillary 20, 704, 234. 00 32, 834, 971. 00 1, 1, 339, 339, 332. 332. 00 00 2, 2, 167, 167, 116. 116. 00 00 Total Bed Days 29, 29, 565 565

2. Routine 14, 503, 448. 00 877, 877, 566. 566. 00 00 Total Inpatient Days 25, 827

3. Special Care 5, 371, 280. 00 328, 328, 083. 083. 00 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 0. 00 00 Medicaid Inpatient Days 1, 644

5. Intern - Resident 0. 00 0. 0. 00 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 13, 258

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Prospective Inflation Factor 1. 1. 1107419712 1107419712

8. Adjustments 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Medicaid Paid Claims 30, 722

9. Total Cost 40, 578, 962. 00 32, 834, 971. 00 2, 2, 544, 544, 981. 981. 00 00 2, 2, 167, 167, 116. 116. 00 00 Property Rate Allowance 1. 1. 1. 00 00 00

10. Charges 170, 427, 002. 00 172, 668, 128. 00 10, 10, 114, 114, 056. 056. 00 00 15, 15, 511, 511, 438. 438. 00 00 First Rate Semester in Effect 2011/ 2011/ 01 01

11. Fixed Costs 7, 671, 457. 00 455, 455, 265. 265. 57 57 Last Last Rate Rate Semester Semester in in Effect Effect 2011/ 07

Ceiling Ceiling and and Target Target Information Information

IPF OF ( F) IP ( G1 OP ( G) Inflation / FPLI Data ( H)

1. Normalized Rate 1, 508. 91 83. 74 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 2. 0060

2. Base Rate Semester 2011/ 01 2011/ 2011/ 01 01 Variable Cost Base 1, 153. 63 70. 30 Cost Report DRI Index 1. 8060

3. Ultimate Base Rate Semester 1991/ 1991/ 01 01 1993/ 01 State Ceiling 1, 739. 90 183. 72 FPLI Year Used 2008

4. 4. Rate Rate of of Increase ( Increase ( Year/ Year/ Sem.) Sem.) I I 1. 021231 1. 031397 County Ceiling 1, 628. 01L 171. 91 FPLI 0. 9357

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) 2, 544, 981. 00 2, 167, 116. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) 455, 265. 57

AD Total Medicaid Variable Operating Cost = ( AA - AB) 2, 089, 715. 43 2, 167, 116. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 2, 321, 134. 64 2, 407, 106. 70

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 1, 644 30, 722

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 1, 411. 88 78. 35

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 1, 411. 88 78. 35

AJ County Rate Ceiling = State Ceiling ( 70% IP & 80% OP) x FPLI ( 0. 9357) for Flagler ( 18) Exempt Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 1, 411. 88 78. 35

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9 276. 93

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 1, 688. 81 78. 35

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 10, 114, 056. 00 15, 511, 438. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 6, 152. 10 504. 90

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 6, 833. 40 560. 81

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 1, 688. 81 78. 35

AU Medicaid Trend Adjustment ( IP%: 14. 6550 %, OP%: 11. 3210 %) 247. 49) 8. 87)

AV Buy Back of Medicaid Trend Adjustment 169. 65 4. 49

AW

AX

AY Final Prospective Rates 1, 610. 96 73. 97

Batch to: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Florida Agency for Health Care Administration 101893 - 101893 - 2012/ 2012/ 07 07

Office of Computation Medicaid Cost of Hospital Reimbursement Prospective Planning Payment Rates and Finance 1671. 1671. 07 / 07 / 83. 83. 46 46

OFdo- We For Rate Semester July 01, 2012 through June 30, 2013

Type of Control: Nonprofit ( Church) Florida Florida Hospital Hospital Flagler Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2010 - 12/ 31/ 2010 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Type of Cost / Charges Inpatient ( A) Outpatient( B) Inpatient ( C) Outpatient ( D) Statistics ( Statistics ( E) E)

1. Ancillary 21, 044, 763. 00 37, 003, 494. 00 1, 203, 254. 00 2, 246, 477. 00 Total Bed Days 36, 36, 135 135

2. Routine 14, 248, 461. 00 750, 951. 00 Total Inpatient Days 25, 693

3. Special Care 4, 850, 798. 00 272, 878. 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 00 Medicaid Inpatient Days 1, 441

5. Intern - Resident 0. 00 0. 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 13, 182

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 00 Prospective Inflation Factor 1. 1. 0988372093 0988372093

8. Adjustments 0. 00 0. 00 0. 00 0. 00 Medicaid Paid Claims 29, 497

9. Total Cost 40, 144, 022. 00 37, 003, 494. 00 2, 227, 083. 00 2, 246, 477. 00 Property Rate Allowance 1. 1. 00 00

10. Charges 173, 818, 971. 00 199, 756, 194. 00 9, 469, 742. 00 17, 045, 522. 00 First Rate Semester in Effect 2012/ 07

11. Fixed Costs 7, 277, 087. 00 396, 459. 24 Last Rate Semester in Effect 2012/ 07

Ceiling and Target Information

IP ( F) OP ( Fl IP ( Gl OP ( G) Inflation / FPLI Data ( H)

1. Normalized Rate 1, 491. 87 89. 89. 44 44 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 2. 0790

2. 2. Base Base Rate Rate Semester Semester 2011/ 07 2011/ 2011/ 07 07 Variable Cost Base 1, 178. 12 72. 51 Cost Report DRI Index 1. 8920

3. 3. Ultimate Ultimate Base Base Rate Rate Semester Semester 1991/ 1991/ 01 01 1993/ 1993/ 01 01 State Ceiling 1, 754. 32 204. 30 FPLI Year Used 2008

4. Rate of Increase ( Year/ Sem.) I 1. 020787 1. 045902 County Ceiling 1, 641. 52 191. 16 FPLI 0. 9357

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) 2, 227, 083. 00 2, 246, 477. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) 396, 459. 24

AD Total Medicaid Variable Operating Cost = ( AA - AB) 1, 830, 623. 76 2, 246, 477. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 2, 011, 557. 51 2, 468, 512. 52

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 1, 441 29, 497

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 1, 395. 95 83. 69

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 1, 395. 95 83. 69

AJ County Rate Ceiling = State Ceiling ( 70% IP & 80% OP) x FPLI ( 0. 9357) for Flagler ( 18) Exempt Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 1, 395. 95 83. 69

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9 275. 13

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 1, 671. 07 83. 69

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 9, 469, 742. 00 17, 045, 522. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 6, 571. 65 577. 87

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 7, 221. 17 634. 99

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 1, 671. 07 83. 69

AU Medicaid Trend Adjustment ( IP%: 14. 3670 %, OP%: 10. 5460 %) 240. 08) 8. 83)

AV Buy Back of Medicaid Trend Adjustment 240. 08 8. 60

AW

AX

AY Final Prospective Rates 1, 671. 071 83. 46

Batch ID: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Florida Agency for Health Care Administration 101893 - 101893 - 2013/ 2013/ 07 07

Office of Computation Medicaid Cost of Hospital Reimbursement Prospective Planning Payment Rates and Finance Outpatient Outpatient Rate: Rate: 86. 86. 72 72

a` For For Rate R, Semester July 01, 2013 through June 30, 2014

Type of Control: Nonprofit ( Church) Florida Florida Hospital Hospital Flagler Flagler County: County: Flagler ( Flagler ( 18) 18)

Fiscal Year: 1/ 1/ 2011 - 12/ 31/ 2011 Type Type of of Action: Action: Field Field Audit Audit District: District: 4 4

Hospital Classification: Rural Hospital

Total Medicaid Medicaid

Type of Cost / Charges Inpatient ( A) Outpatient ( Bl Inpatient ( Inpatient ( C) C) Outpatient ( Outpatient ( D) D) Statistics ( Statistics ( E) E)

1. Ancillary 20, 658, 947. 00 38, 276, 003. 00 1, 1, 234, 234, 792. 792. 00 00 2, 2, 336, 336, 415. 415. 00 00 Total Bed Days 30, 30, 295 295

2. Routine 14, 507, 140. 00 861, 861, 407. 407. 00 00 Total Inpatient Days 25, 754

3. Special Care 5, 038, 907. 00 324, 324, 451. 451. 00 00 Total Newborn Days 0 0

4. Newborn Routine 0. 00 0. 0. 00 00 Medicaid Inpatient Days 1, 509

5. Intern - Resident 0. 00 0. 0. 00 00 Medicaid Newborn IP Days 0 0

6. Home Health Medicare Inpatient Days 13, 519

7. Malpractice 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Prospective Inflation Factor 1. 1. 1. 0395395395 0395395395 0395395395

8. Adjustments 0. 00 0. 00 0. 0. 00 00 0. 0. 00 00 Medicaid Paid Claims 27, 979

9. Total Cost 40, 204, 994. 00 38, 276, 003. 00 2, 2, 420, 420, 650. 650. 00 00 2, 2, 336, 336, 415. 415. 00 00 Property Rate Allowance 1. 1. 00 00

10. Charges 176, 215, 779. 00 214, 794, 478. 00 9, 9, 471, 471, 078. 078. 00 00 17, 17, 292, 292, 987. 987. 00 00 First Rate Semester in Effect 2013/ 07

11. Fixed Costs 10, 157, 425. 00 545, 545, 931. 931. 61 61 Last Rate Semester in Effect 2013/ 07

Ceiling Ceiling and and Target Target Information Information

IP ( F) OP ( Fl IP ( G) OP ( G) Inflation / FPLI Data ( H)

1. Normalized Rate 1, 380. 23 92. 77 County County Ceiling Ceiling Base Base Exempt Exempt Semester DRI Index 2. 0770

2. Base Rate Semester 2012/ 07 2012/ 07 Variable Cost Base 1, 202. 61 75. 84 Cost Report DRI Index 1. 9980

3. Ultimate Base Rate Semester 1991/ 01 1993/ 01 State Ceiling 1, 695. 69 197. 52 FPLI Year Used 2008

4. Rate of Increase ( Year/ Sem.) 1 1. 0118161 1. 026091 County Ceiling 1 1, 586. 66 184. 82 FPLI 0. 9357

Rate Calculations

Rates are based on Medicaid Costs Inpatient Outpatient

AA Inpatient based on Medicaid Cost ( C9) : Outpatient based on Medicaid Cost( D9) Reimbursed by 2, 336, 415. 00

AB Apportioned Medicaid Fixed Costs = Total Fixed Costs x ( Medicaid Charges/ Total Charges) Diagnosis

AD Total Medicaid Variable Operating Cost = ( AA - AB) Related Groups 2, 336, 415. 00

AE Variable Operating Cost Inflated = ( AD x Inflation Factor ( E7)) 2, 428, 795. 77

AF Total Medicaid Days ( Inpatient E4 E5) or Medicaid Paid Claims ( Outpatient) 27, 979

AG Variable Cost Rate: Cost Divided by Days ( IP) or Medicaid Paid Claims ( OP) 86, 81

AH Variable Cost Target = Base Rate Semester x Rate of Increase ( G2 x F4) Exempt

Al Lesser of Inflated Variable Cost Rate ( AG) or Target Rate ( AH) 86. 81

AJ County Rate Ceiling = State Ceiling ( 70% IP & 80% OP) x FPLI ( 0. 9357) for Flagler ( 18) Exempt

AK County Ceiling Target Rate = County Ceiling Base x Rate of Increase ( G1 x F4) Exempt

AL Lesser of County Rate Ceiling ( AJ) or County Ceiling Target Rate ( AK) Exempt

AM Lesser of Variable Cost ( AI) or County Ceiling ( AL) 86. 81

AN Plus Rate for Fixed costs and Property Allowance = ( C11/ AF) x E9

AP Total Rate Based on Medicaid Cost Data = ( AM AN) 86. 81

AQ Total Medicaid Charges, Inpatient ( C10): Outpatient ( D10) 17, 292, 987. 00

AR Charges divided by Medicaid Days ( Inpatient) or Medicaid Paid Claims ( Outpatient) 618. 07

AS Rate based on Medicaid Charges adjusted for Inflation ( AR x E7) 642. 51

AT Prospective Rate = Lesser of rate based on Cost ( AP) or Charges ( AS) 86. 81

ALI Medicaid Trend Adjustment ( IP%: 10. 4400 %, OP%: 10. 0940 %) 8. 76)

AV Buy Back of Medicaid Trend Adjustment 8, 67

AW

AX

AY Final Prospective Rates 86. 72

Batch ID: MBX9Y Created On: 6/ 19/ 2017 Published: 6/ 19/ 2017 Report Printed: 6/ 19/ 2017

Provider Cost Rate Report ear Medicaitl Days in OP-

Number prov der Nama ReportCost ReportPeriotl Rate Period Ending IP - Current IP - New IP- Rate IP- Impast of Rate Current OP - New OP- 00g Pate in OP- Impast of Rate

Year Begin Yaar End Begin End Only Rate Rate V 1 p d d Ch nge Rate Rate Va ante per od Change

IP 5 ( 36, 816. 30)

Lump sum fiscal yellow Please highlighted n[ e that the

noP unt ( oyer All z veprsl of IP 6 cel a6, Is e:. are estimatM

5 ( u, 6da. o2

22, 828. 50

Copy of Adventist Master Spreadsheet 6/ 11/ 2019