59G-6.005. Reimbursement Methodology for Services Provided by Medical School Faculty

(1) This rule applies to all providers who are enrolled in Florida Medicaid who:

(a) Are defined as practitioners under the Centers for Medicare and Medicaid Services’ Merit-based Incentive Payment System (MIPS).

(b) Provide medical services, dental services, behavioral health services, hearing services, and vision services to Florida Medicaid recipients receiving services through the fee-for-service delivery system.

(c) Are employed by, or contracted with, a Florida public or private, non-profit, accredited medical, dental, or optometry school to provide supervision and teaching of medical, dental, or optometric students, residents, or fellows.

(2) Reimbursement.

(a) Florida Medicaid reimburses providers for covered medical, hearing, vision, dental, and behavioral health services listed on the applicable Florida Medicaid fee schedule, incorporated by reference in Rule 59G-4.002, F.A.C., at either:

1. Two hundred-three percent of the Medicare rate, based on Florida locality code 0910299, listed on the 2018 Medicare Part B physician fee schedule – Loc 03, 04, and 99, incorporated by reference, and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-13315, https://ahca.myflorida.com/medicaid/review/Reimbursement/2018-01-01_Fee_Schedules/Practitioner_Fee_Schedule_2018.pdf, and at Physician Fee Schhttps://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspxedule Search (cms.gov).

2. Two hundred-three percent of the Florida Medicaid rate if the service is not covered by Medicare.

(b) Florida Medicaid reimbursement to providers for clean claims submitted to the Florida Medicaid Management Information System specified in this rule shall not exceed the amount specified in the General Appropriations Act.

(c) Florida Medicaid will reconcile claims reimbursed in accordance with this rule on a quarterly basis. Any claims reimbursed after the maximum reimbursable amount is reached will be recouped, or adjusted to the standard Florida Medicaid rate, as appropriate.

(3) Exclusions. Florida Medicaid does not reimburse providers in accordance with this rule for the following:

(a) Services rendered to dually eligible Medicare and Medicaid recipients.

(b) Vaccine, laboratory, and radiology services.

(4) This rule is in effect for five years from its effective date.

Rulemaking Authority 409.919 FS. Law Implemented 409.908 FS. History–New 6-13-17, Amended 12-25-18, 8-15-21.