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

SUMMARY: The rule describes copayment and coinsurance requirements for Florida Medicaid recipients and service providers.

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: 409.9081 FS.

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

DATE AND TIME: April 27, 2016 9:30 a.m. – 10:00 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: 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 IS: Ray Aldridge, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]. Official comments to be entered into the rule record will be received from the date of this notice until May 2, 2016. Comments may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

59G-1.056 Copayments and Coinsurance.

(1) This rule applies to providers rendering Florida Medicaid services to recipients.

(2) Requirement. Recipients are responsible for paying all applicable copayment and coinsurance amounts directly to the provider who furnished Florida Medicaid covered services.

(3) Amounts. The copayment and coinsurance amounts, as specified in section 409.9081, Florida Statutes, are as follows:

SERVICE	FEE
Chiropractor services, per provider or group provider, per day	$1.00
Community behavioral health services, per provider, per day	$2.00
Home health services, per provider, per day	$2.00
Hospital outpatient services, per visit	$3.00
Federally qualified health center visit, per clinic, per day	$3.00
Independent laboratory services, per provider, per day	$1.00
Non-emergency transportation services, per each one-way trip	$1.00
Nurse practitioner services, per provider or group provider, per day	$2.00
Optometrist services, per provider or group provider, per day	$2.00
Physician and physician assistant, per provider or group provider, per day	$2.00
Podiatrist services, per provider or group provider, per day	$2.00
Portable x-ray services, per provider, per day	$1.00
Rural health clinic visit, per clinic, per day	$3.00
Use of the hospital emergency department for non-emergency services	5% of the first $300.00 of the Florida Medicaid payment (maximum $15.00)

(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 may not deny services 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 recipients eligible for Medicare) 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_______.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Ray Aldridge

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

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: February 16, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 30, 2015