The purpose of Rule 59G-6.025, Florida Administrative Code (F.A.C.), is to specify Florida Medicaid’s payment methodology for cancer hospitals that meet certain criteria and are enrolled in the Florida Medicaid program. The methodology calculates ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-6.025Reimbursement Methodology for Cancer Hospitals

PURPOSE AND EFFECT: The purpose of Rule 59G-6.025, Florida Administrative Code (F.A.C.), is to specify Florida Medicaid’s payment methodology for cancer hospitals that meet certain criteria and are enrolled in the Florida Medicaid program. The methodology calculates enhanced reimbursement for inpatient and outpatient services rendered at H. Lee Moffitt Cancer Center and the University of Miami Hospital and Clinics d/b/a/ Sylvester Comprehensive Cancer Center.

SUBJECT AREA TO BE ADDRESSED: Reimbursement Methodology for Cancer Hospitals.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.905, 409.908 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: November 2, 2018 from 11:00-11:30 a.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, 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: T. K. Feehrer 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 DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: T. K. Feehrer, Bureau of Medicaid Program Finance, 2727 Mahan Drive, Mail Stop 23, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m. on November 5, 2018 and may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-6.025 Reimbursement Methodology for Cancer Hospitals.

(1) This rule applies to Florida Medicaid providers that render inpatient and outpatient hospital services to recipients through the fee-for-service delivery system. The providers must be considered as a cancer hospital and:

(a) Be members of the Alliance of Dedicated Cancer Centers.

(b) Meet the criteria under Title 42, United States Code, section 1395ww(d)(1)(B)(v).

(2) Definitions.

(a) Upper Payment Limit (UPL) - The annual maximum amount Florida Medicaid may pay in the aggregate to inpatient hospitals for inpatient and outpatient services rendered under the Florida Medicaid fee-for-service delivery system.

(b) UPL Gap - The difference between the annual maximum amount Medicare would pay to a cancer hospital for inpatient and outpatient hospital services rendered to recipients and the actual amount paid by Florida Medicaid for those services.

(c) Valid Claim - A “clean claim” as defined in Rule 59G-1.010, Florida Administrative Code, for inpatient and outpatient hospital services that meet all of the following:

1. Provided by a cancer hospital under the fee-for-service delivery system.

2. Provided to Florida Medicaid recipients who are not also eligible for Medicare.

(3) Reimbursement.

(a) Effective October 26, 2017, Florida Medicaid reimburses cancer hospitals for inpatient and outpatient hospital services rendered to eligible Florida Medicaid recipients in an amount up to each hospital’s UPL, in accordance with Title 42, Code of Federal Regulations (CFR), section 447.272.

(b) Florida Medicaid calculates supplemental payments to cancer hospitals based upon the UPL gap.

(c) Florida Medicaid reimbursement to providers for state fiscal year (SFY) 2017-2018 will be prorated by using the ratio of effective dates within SFY 2017-2018 and multiplying the ratio by the UPL gap for hospital inpatient and outpatient services. The calculated ratio for SFY 2017-2018 is 0.6795.

(d) Florida Medicaid will calculate supplemental payments quarterly, based on valid claims that have a paid date within the previous three months.

Rulemaking Authority 409.919 FS. Law Implemented 409.905, 409.908 FS. History–New ________.