The purpose of Rule 59G-1.056 is to establish Florida Medicaid copayment and coinsurance responsibilities for Florida Medicaid covered services.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-1.056Copayments and Coinsurance

PURPOSE AND EFFECT: The purpose of Rule 59G-1.056 is to establish Florida Medicaid copayment and coinsurance responsibilities for Florida Medicaid covered services.

SUBJECT AREA TO BE ADDRESSED: Rules 59G-1.056, F.A.C., Copayments and Coinsurance; F.A.C., 59G-1.052, F.A.C., Third-Party Liability Requirements; and 59G-1.054, F.A.C., Recordkeeping and Documentation Requirements.

An additional area to be addressed during the workshop will be the potential regulatory impact Rules 59G-1.056, 59G-1.052, and 59G-1.054, F.A.C., will have as provided for under sections 120.54 and 120.541, FS.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.9081 FS.

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

DATE AND TIME: November 16, 2015, 2:00 ‒ 4:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room B, 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: Ray Aldridge. 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: Ray Aldridge, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], email: [e-mail]

Comments will be received until 5:00 p.m., on November 17, 2015.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-1.056 Copayments and Coinsurance.

(1) This rule applies to all recipients receiving Florida Medicaid services, and all providers of Florida Medicaid services who are enrolled in or registered with the Florida Medicaid program.

(2) Requirement. Recipients are responsible for paying all applicable copayment and coinsurance amounts directly to the provider who furnished Florida Medicaid covered services, unless otherwise exempt, or if the copayment or coinsurance is waived by the Florida Medicaid managed care plan in which the recipient is enrolled.

(3) Amounts. The copayment and coinsurance amounts, as specified in section 409.9081, Florida Statutes, are included in the service-specific coverage policies codified in Rule Chapter 59G-4, Florida Administrative Code.

(4) Exemptions. The following categories of recipients are not required to pay a copayment or coinsurance:

(a) Individuals under the age of 21 years.

(b) Pregnant women – for pregnancy-related services, including services for medical conditions that may complicate the pregnancy. This exemption includes the six week period following the end of the pregnancy.

(c) Individuals receiving services in an inpatient hospital setting, long-term care facility, or other medical institution if, as a condition of receiving services in the institution, that individual is required to spend all of his or her income for medical care costs with the exception of a minimal amount required for personal needs.

(d) Individuals who require emergency services after the sudden onset of a medical condition, which if left untreated would place their health in serious jeopardy.

(e) Individuals receiving services or supplies related to family planning.

(5) Recipients Unable to Pay. Providers cannot deny service to a recipient based solely on the recipient’s inability to pay a Florida Medicaid copayment or coinsurance amount. Providers may bill the recipient for the unpaid copayment or coinsurance amount.

(6) Third-Party Coverage. Recipients who have third-party liability coverage (including dually eligible recipients) are required to pay copayment or coinsurance amounts, unless:

(a) The recipient is otherwise exempt.

(b) The Medicare or third-party payment is equal to, or exceeds, the Florida Medicaid fee for the service. Providers must reimburse recipients who have paid a Florida Medicaid copayment when the Medicare or third-party liability payment is equal to or exceeds the Florida Medicaid fee for the service.

Rulemaking Authority 409.919 FS. Law Implemented 409.9081 FS. History-New_______.