The purpose of the amendment to Rule 59G-5.110 is to describe the circumstances, process, and requirements for Florida Medicaid recipients to receive direct reimbursement from the Agency for Health Care Administration for goods and services that ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-5.110Claims Payment

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-5.110, F.A.C. is to describe the circumstances, process, and requirements for Florida Medicaid recipients to receive direct reimbursement from the Agency for Health Care Administration for goods and services that were provided to and paid for by the recipient. The rule amendment also revises the rule title to Direct Reimbursement to Recipients.

SUMMARY: The amendment describes the Florida Medicaid recipient direct reimbursement process.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.902 FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: February 5, 2016, 9:30 a.m. ‒ 10:30 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Virginia Hardcastle. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Virginia Hardcastle, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]. Comments will be received until 5:00 p.m., on February 8, 2016.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-5.110 Direct Reimbursement to Recipients Claims Payment.

(1)(a) Purpose. This rule describes the circumstances when the Agency for Health Care Administration (AHCA) may directly reimburse eligible Florida Medicaid recipients; how AHCA reimburses recipients; and documentation requirements for direct reimbursement.

(2) Determination Criteria. Florida Medicaid recipients may be eligible for direct reimbursement if:

(a) Medical goods and services were paid for by the recipient or a person legally responsible for their bills from the date of an erroneous denial or termination of Florida Medicaid eligibility to the date of a reversal of the unfavorable eligibility determination.

(b) The goods and services were medically necessary as defined in Rule 59G-1.010, Florida Administrative Code (F.A.C.); rendered by a provider that is qualified to perform the service including meeting any applicable certification or licensure requirements (the provider is not required to be enrolled or registered as a Florida Medicaid provider); and covered by Florida Medicaid for the recipient’s eligibility group on the date of service.

(c) Reimbursement for the medical goods or services is not available through any third-party payer on the date of service for which direct reimbursement is requested.The agency provides eligible individuals with access to Medicaid services and goods by direct payment to the Medicaid provider upon submission of a payable claim to the fiscal agent contractor. Except as provided for by law or federal regulation, payments for services rendered or goods supplied shall be made by direct payment to the provider except that payments may be made in the name of the provider to the provider’s billing agent if designated in writing by the provider. Direct payment may be made to a recipient who paid for medically necessary, Medicaid-covered services received from the beginning date of eligibility (including the three-month retroactive period) and paid for during the period of time between an erroneous denial or termination of Medicaid eligibility and a successful appeal or an agency determination in the recipient’s favor. The services must have been covered by Medicaid at the time they were provided.

(3) Reimbursement Process. Recipients must submit direct reimbursement requests to AHCA within 12 months of the date of the reversal of the unfavorable eligibility determination described in paragraph (2)(a).

(a) The reimbursement request must include evidence of all out-of-pocket expenses paid to the provider, validated through Medicaid will send payment directly to the recipient upon submission of valid receipts submitted by the recipient to: the Agency for Health Care Administration, 400 W. Robinson St., Suite S-309, Orlando, FL 32801. All payments shall be made at the Medicaid established payment rate in effect at the time the services were rendered. Any services or goods the recipient paid before receiving an erroneous determination or services for which reimbursement from a third party is available are not eligible for reimbursement to the recipient.

(b) Recipients will be notified in writing of their right to reimbursement . This information shall be given when they are notified that their appeal has been upheld or the agency determines before the hearing that an erroneous decision was made. This notice shall be provided on a Medicaid Direct Payment Notice to Applicant or Recipient, AHCA 5240-0001 (November 1998), incorporated by reference.

(b)(c) The Agency for Health Care Administration will send If Medicaid needs additional information from a recipient to determine eligibility for direct reimbursement, Medicaid will notify the recipient in writing on a Florida Medicaid Direct Reimbursement Recipient Information Request Payment Notice, AHCA Form 5240-0002, ________(November 1998), incorporated by reference in Rule 59G-1.045, F.A.C., to recipients if more information is required to determine their eligibility for direct reimbursement. Recipients must complete and return the signed form in accordance with the instructions provided on the form.

(c)(d) The Agency for Health Care Administration will send If Medicaid needs additional information from a provider, and the recipient is not able to obtain the information, Medicaid will request the information from the provider in writing on a Florida Medicaid Direct Reimbursement Provider Information Request Payment Notice to Provider, AHCA Form 5240-0003, _________(November 1998), incorporated by reference in Rule 59G-1.045, F.A.C., if more information is needed from the provider to determine recipient eligibility for direct reimbursement. Providers must complete and return the signed form in accordance with the instructions provided on the form.

(4)(e) Recipient Notification. The Agency for Health Care Administration will send reimbursement directly to the recipient in the amount the recipient paid to the provider. If AHCA determines that the expenses do not qualify for reimbursement, the recipient will be notified Medicaid will notify recipients in writing after all information has been reviewed whether they are eligible for direct reimbursement on a Medicaid Direct Payment Notice of Disposition, AHCA 5240-0004 (November 1998), incorporated by reference.

(5) Fair Hearing. The recipient has the right to request a Medicaid fair hearing if notified that reimbursement in full or in part is not approved. A request for a fair hearing must be made within 90 days from the date the notification is mailed to the recipient. The fair hearing may be requested by calling the Medicaid Helpline at 1-877-254-1055 or by contacting the Department of Children and Families Office of Appeal Hearings at [e-mail].

(2) Charges for services or goods billed to the Medicaid program shall not exceed the provider’s lowest charge to any other third party payment source for the same or equivalent medical and allied care, goods, or services provided to person who are not Medicaid recipients. Any services or goods customarily provided free of charge to patients may not be billed to Medicaid when provided to Medicaid recipients. Any payment made by Medicaid for services or goods not furnished in accordance with these provisions is subject to recoupment and the agency may, in such instances, initiate other appropriate administrative or legal action.

(3) The signature of the provider, his employees, or authorized billing agent shall be entered on all claims submitted to the Medicaid program. If a facsimile signature is used on the claim form, an authorized individual must also write their initials on the claim form. Because electronic claims can not be submitted with a signature on each claim, the provider’s endorsed signature on the back of the check issued by Medicaid takes the place of a signature on a claim, acknowledging the submission of the claims and receipt of payment for those claims, as well as certifying compliance with all federal and state laws.

(4) The provider cannot seek payment from a recipient for a compensable service for which a claim has been submitted, regardless of whether the claim has been approved, partially approved or denied by the agency.

Rulemaking Authority 409.919 FS. Law Implemented 42 CFR 431.246, 409.902, 409.907, 409.908 FS., 42 C.F.R. s. 447.25. History–New 9-22-93, Formerly 10P-5.110, Amended 5-9-99,____________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Kathy Austin

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: December 28, 2015

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 1, 2015