The Agency is amending the rules relating to HCRA to clarify definitions, remove outdated information, update the reimbursement rate notification reference, clarify timeliness of report submission requirements, implement standards for overpayment to ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Health Care Responsibility Program

RULE NOS.:RULE TITLES:

59H-1.0035Definitions

59H-1.0045County Financial Responsibility

59H-1.0055Hospital Participation

59H-1.0065Covered Services

59H-1.008Determination of a Qualified Indigent Patient

59H-1.010Reimbursement Procedures

59H-1.015Administrative Hearings, Applicant's Rights and Responsibilities

PURPOSE AND EFFECT: The Agency is amending the rules relating to HCRA to clarify definitions, remove outdated information, update the reimbursement rate notification reference, clarify timeliness of report submission requirements, implement standards for overpayment to hospitals and parties with rights to the appeal process.

SUMMARY: Rule 59H-1.0035 is amended to change “individual” to “applicant” for clarification, remove outdated language, revise forms to be available on website, and update the name of the responsible Agency business unit. Rule 59H-1.0045 is amended to change the term “per diem” to “reimbursement” to comply with the payment methodology for inpatient claims that are being revised to conform to legislative changes that became effective on July 1, 2013, to clarify submission timeliness, and update the name of the responsible Agency business unit. Rule 59H-1.0055 is amended to update the name of the responsible Agency business unit, and add clarification that county is not responsible for payment until hospital has met its obligation. Rule 59H-1.0065 is amended to remove outdated language. Rule 59H-1.008 is amended to add that hospitals are responsible for assisting applicants in completing applications, to clarify submission timeliness, change notification requirements for certifying agencies, and make technical changes. Rule 59H-1.010 is amended to clarify submission timeliness, and update name of form. Rule 59H-1.015 is amended to clarify which parties have appeal rights and responsibility to repay any amount paid because of an inappropriate eligibility determination.

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.

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: 154.3105 FS.

LAW IMPLEMENTED: 154.304, 154.306, 154.308, 154.309, 154.31, 154.312, 154.314 FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: April 21, 2016, 1:30 p.m. ‒ 2:30 p.m.

PLACE: Agency for Health Care Administration Ft. Knox Bldg. 3, Conference Room D, 2727 Mahan Drive, Tallahassee, FL 32308

Interested parties that would like to join the hearing by phone can do so by using a call-in number and passcode:

Call-in Number: 1(888)670-3525, Participant Passcode: 6396795315#

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 3 days before the workshop/meeting by contacting: Kirsten Jacobson, [phone] or [e-mail]. 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: Kirsten Jacobson, [phone] or [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59H-1.0035 Definitions.

The following words and phrases shall have the following meanings for the purpose of this rule.

(1) Act: The Florida Health Care Responsibility Act (HCRA or Program).

(2) Adequate Third Party Insurance: Coverage of the hospitalization by a third party insurer that would be equal to or greater than either: 80 percent of the amount the hospital would receive if reimbursed at the hospital’s Medicaid outpatient per diem rate or inpatient payment method utilizing Diagnosis-Related Groups (DRG) for Florida Medicaid, or the reimbursement rate negotiated by the county with the affected hospitals, if that negotiated rate is greater than 80 percent of the Medicaid hospital’s outpatient per diem rate or inpatient payment method utilizing DRG for Florida Medicaid.

(3)Agency: Agency for Health Care Administration. As defined in Section 154.304(1), F.S., (AHCA). 

(4) Applicant: Any person who applies, through written application, for medical assistance coverage for hospital services under the Health Care Responsibility Act.

(5) Application: The Health Care Assistance Application, AHCA Form 5220-0001, February 2016 December 1998, as revised in consultation with the hospitals and the counties and incorporated by reference, used to apply for coverage for hospital services under the aAct. The application must include at least the individual’s name, date of birth, living address, mailing address, citizenship and signature to initiate the process. Only one hospital visit per applicant shall be submitted on a single application.  Interested parties may obtain copies of the application from the HCRA Handbook Agency for Health Care Administration, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop Code 26, Tallahassee, Florida 32308.

(6) Assets: Those items defined as assets in 20 CFR 416 for determining eligibility for Supplemental Security Income (SSI), except as otherwise provided in Rule 59H-1.008, F.A.C., shall be used in determining eligibility under the aAct.

(7) Asset Limits: The overall amount of countable assets a an applicant person may retain and still remain eligible. This amount shall be the same as used in the Medicaid medically needy program as defined in Rule 65A-1.716, F.A.C.

(8) Certified Resident: A United States citizen or lawfully admitted alien who is has been certified by a Florida county or the aAgency as being a resident of that county at the time the need for hospital care was rendered arose.

(9) Certifying Agency: The person or office designated by the county of residence unit or agency unit responsible for determining patient eligibility and certifying the county of residency under the Aact. The Agency will make this determination on behalf of the county of residence only if it is unable to do so for circumstances beyond their control. Such determinations made by the Agency may not be disputed by the county of residence.

(10) Charity Care Obligation: As defined in Section 154.304(4), F.S. The ratio of uncompensated charity care days compared to total acute care inpatient days provided by a given hospital which is equal to or greater than 2 percent, based on the hospital’s most recent audited actual experience, as reported to the Agency for Health Care Administratoion, Division of Need/Financial Analysis.

(11) Claim: The universal hospital billing form, UB 04/CMS-1450 UB 92/HCFA-1450., incorporated by reference. Interested parties may obtain a A copy of this form may be obtained the UB 92/HCFA-1450 from the district Medicaid office.

(12) County fiscal year: October 1 of a given year through September 30 of the subsequent calendar year.

(13) County of Residence:

(a) A specific county within the State of Florida where an individual establishes or maintains a living arrangement, outside of a medical facility, and which the individual, or someone responsible for the individual, considers to be the individual home with the intent to remain a resident of that county. A visit to another county for any purpose does not make a person a resident of that county, nor does a temporary living arrangement prior to admission in a medical facility. The length of time a person physically resides in a county is not a factor in determining residency. If the applicant or a member of the applicant’s family unit maintains a primary residence in another county with the intent to return to that county, then the county of residence is the county in which the primary residence is located.

(b) A student attending school away from home is considered a resident of the county in which the student’s parents reside if the student is claimed as a dependent for Federal Income Tax purposes. In those situations where one parent resides in-state and one parent resides out-of-state, the county where a parent resides in-state is the county of residence, even if the in-state parent is not claiming the student as a dependent for tax purposes.

(14) Designated Representative: An individual who has knowledge of the applicant’s circumstances and is authorized to act assumes responsibility for acting responsibly on behalf of an applicant or recipient by providing information, verification and documentation required by the certifying agency to determine eligibility.  A designated representative may not have any monetary gain due to an applicant’s status as an eligible individual or due to the counties reimbursement of the applicant’s claim.

(15) Eligible Individual: An applicant individual who is a certified resident of a Florida the county, has met the Act’s criteria in regards to income, assets, and other eligibility requirements, who has received covered hospital services from a participating out of county hospital, a regional referral hospital or an in-county eligible hospital and who is either a qualified indigent patient or a spend-down provision eligible patient. An in-county eligible hospital is a hospital located in a county that has elected to use up to one half of its HCRA designated funds to reimburse its in-county hospitals for in-county indigent care.

(16) Emergency Medical Condition: As defined in Section 409.901(10), F.S. A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, or other acute symptoms such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

(a) Serious jeopardy to the health of a patient;

(b) Serious impairment of any bodily functions;

(c) Serious dysfunction of any bodily organ or part.

(d) With respect to a pregnant woman:

1. That there is inadequate time to effect safe transfer to another hospital prior to delivery.

2. That a transfer may pose a threat to the health and safety of the patient or fetus.

3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.

(17) Emergency Services and Care: As defined in Section 409.901(11), F.S. Medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of the hospital.

(18) Family Unit: One or more persons residing together in the same household whose needs, income and assets are included in the household budget, excluding roomers and boarders. Members may include the applicant, legal spouse, partner, dependent children, stepchildren, adopted children and blood relatives under 21 years of age, unrelated minor children for whom the applicant, the applicant’s spouse, or partner has legal guardianship or custody, legal guardian or parents of minor children, minor siblings, and partner’s children under the age of 21.

(a) A boarder is a person for whom payment is made for room and meals and who is not the spouse or partner of the landlord.

(b) A roomer is a person for whom a payment is made for a room and who is not the spouse or partner of the landlord.

(c) An applicant who is a roomer or boarder must verify the applicant’s status as a roomer or boarder by providing a written statement from the landlord stating that the applicant is a roomer or boarder, the amount of the cash payment, that the cash payment is for a room or a room and meals, and that the applicant is not the spouse or partner of the landlord.

(d) An applicant who wishes to exclude a person from the applicant’s family unit based on the fact that the person is a roomer or boarder must verify that person’s status as a roomer or boarder by providing a written statement from the person stating that the applicant is a roomer or boarder, the amount of the cash payment, that the cash payment is for a room or a room and meals, and that the person is not the spouse or partner of the landlord.

(19) Gross Family Income: The sum of gross income a family unit receives or is entitled to receive at the time of eligibility determination, as defined under Section 154.308(4), F.S. Income shall include the following:

(a) Wages and salary;

(b) Child support;

(c) Alimony;

(d) Unemployment compensation;

(e) Worker’s compensation;

(f) Veteran’s pension;

(g) Social security;

(h) Pensions or annuities;

(i) Dividends;

(j) Interest on savings or bonds;

(k) Income from estates or trusts;

(l) Net rental income or royalties;

(m) Net income from self-employment; and

(n) Contributions from any source, including any amount contributed toward the support of any individuals and not otherwise excluded under the HCRA guidelines.

(20) HCRA Handbook: The Florida Health Care Responsibility Act (Act, HCRA, or Program) Handbook, February 2016, AHCA Form, 3160-0016, Revised March 17, 1999, created by and revised by the agency in consultation with the hospitals and the counties, and herein incorporated by reference, for the purpose of providing detailed and uniform policies and procedures to the hospitals, counties and others in complying with the applicable statutes and administrative rules.  Copies of the HCRA Handbook may be obtained at https://www.flrules.org/Gateway/reference.asp?No=Ref-XXXXX and from the Agency’s HCRA website at http://www.ahca.myflorida.com/MCHQ/Central_Services/Financial_Ana_Unit/HCRA/index.shtml for Health Care Administration, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop Code 26, Tallahassee, Florida 32308.  The following forms are included in the HCRA Handbook and are incorporated by reference:  Health Care Assistance Application, AHCA Form 5220-0001, February 2016; Monthly Caseload and Appeals Report, AHCA Form 3160-0017, February 2016; Notification of Eligibility, AHCA Form 5220-0002, February 2016; and Quarterly Financial Report, AHCA Form 3160-0018, February 2016. 

(21) Homestead: House, trailer, boat or motor vehicle in which the family unit resides and which is owned by the applicant patient or a member of the applicant’s family unit. Only one homestead shall be excluded as an asset. The composition and value of real property shall be determined by the county property appraiser. If the family unit leaves the homestead and establishes residence elsewhere, the homestead becomes an asset regardless of how it is considered for tax purposes. If a member of the family unit continues to reside in the homestead, it will not be considered an asset. If, in the case of a single person family unit, the individual is absent because of a physical or mental illness, and the individual intends to return, the homestead will not be considered as an asset.

(22) Hospital: As defined in Section 154.304(7), F.S. An establishment defined in Section 395.002, F.S., and qualified by the agency as either a participating hospital or a regional referral hospital. Hospitals operated by the State of Florida shall not be considered participating hospitals.

(23) Inpatient: A patient of a hospital who (1) receives professional services in the hospital for a 24-hour period or longer, or (2) is expected by the hospital to receive professional services in the hospital for a 24 hour period or longer even though it later develops that the patient dies, is discharged or is transferred to another facility and does not actually stay in the hospital for 24 hours.

(24)(23) Maximum County Financial Responsibility: That amount obtained by multiplying total county population, as defined in Section 154.306(3), F.S., by $4 per capita using the most recent official state population estimate for the total county population published by the Florida Legislature’s Executive Office of the Governor and the Bureau of Economic and Demographic Business Research.

(25)(24) Medicaid Program: As defined in Section 409.901(16), F.S. The medical assistance program under Title XIX of the Social Security Act and Chapter 409, F.S.

(26)(25) Monthly Caseload and Appeals Report: The form, Monthly Caseload and Appeals Report, AHCA Form 3160-0017, Revised December 1998, February 2016, incorporated by reference, used by the counties on a monthly basis and submitted by the 15th of the month following the end of the reported month to the Agency to document and report caseload activity on applications and appeals to the agency on a monthly basis. Copies of the report form may be obtained from the HCRA Handbook for Health Care Administration, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop Code 26, Tallahassee, Florida 32308.

(27)(26) Notification of Eligibility: The form, Notification of Eligibility, AHCA Form 5220-0002, December 1998, as revised by the agency, in consulation with the hospitals and counties, February 2016 and incorporated by reference, used by the Certifying Agency to notify applicants and hospitals of the eligibility determination disposition of an application. Interested parties may obtain Ccopies of the notification form may be obtained from the HCRA Handbook for Health Care Administration, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop Code 26, Tallahassee, Florida 32308.

(28) Outpatient:  A patient of a hospital who receives professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the hospital past midnight.  Only one day’s services are billable on one outpatient claim. 

(29)(27) Participating Hospital: As defined in Section 154.304(8), F.S. A hospital, that has met its charity care obligation, as defined in subsection 59H-1.0035(10), F.A.C., and has either:

(a) A formal signed agreement with a county or counties to treat such county’s indigent patients; or

(b) Demonstrated that at least 2.5 percent of its uncompensated charity care, based on the hospital’s most recent audited actual experience as reported to the Bureau of Certificate of Need/Financial Analysis, is generated by out-of-county residents.

(30)(28) Poverty Guidelines: The family federal poverty measure income levels published annually in the Federal Register by the U.S. Department of Health & Human Services Federal Office of Management and Budget (OMB) and as posted by the Federal Register (formally known as the Federal Poverty Level, or FPL).

(31)(29) Public Institution: Institution over which a governmental unit exercises administrative control, such as a correctional institution or holding facility for individuals who are prisoners, have been arrested or detained pending dispositions of charges, or are held under court order as material witnesses or juveniles. Public institution is further defined under the medical assistance program under Title XIX of the Social Security Act, as amended, in 42 CFR, Chapter IV, Section 435.1009, F.S.

(32)(30) Qualified Indigent Patient: As defined in Section 154.304(9), F.S. An applicant whose gross family unit income, for the 12 months preceding the determination, has been equal to or below 100 percent of federal poverty level; who is not eligible to participate in any other state or federal program which provides hospital care; has assets that do not exceed standards specified in subsection 59H-1.0035(6), F.A.C.; who has no private insurance or inadequate private insurance; and who does not reside in a public institution as defined under the medical assistance program under Title XIX of the Social Security Act, as amended.

(33)(31) Quarterly Financial Report: The form, Quarterly Financial Report, AHCA Form 3160-0018, Revised Dec. 1998, February 2016, and incorporated by reference, used by the counties on a quarterly basis and submitted within 30 calendar days following the end of the reported quarter to the Agency to document and report expenditures and claim activity to the agency on a quarterly basis. Copies of the report form may be obtained from the HCRA Handbook Agency for Health Care Administration, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop Code 26, Tallahassee, Florida 32308.

(34)(32) Regional Referral Hospital: As defined in Section 154.304(10), F.S. Any hospital which has met its charity care obligation as defined in subsection 59H-1.0035(10), F.A.C. and meets the definition of teaching hospital as defined in Section 408.07(49), F.S.

(35)(33) Share of Cost: The share of cost is the difference between the spend-down provision applicant’s monthly gross family income and the amount of income equal to 100 percent of the federal poverty guidelines level specified for the size of the applicant’s family unit.

(36)(34) Spend-down Provision: The provision through which an applicant who meets the following criteria becomes eligible by meeting a share of cost requirement. Such an applicant must:

(a) Be a resident of a spend-down provision eligible county as defined in subsection 59H-1.0035(37), F.A.C.;

(b) Meet the definition of a qualified indigent patient as defined in subsection 59H-1.0035(303), F.A.C., excluding the income requirement;

(c) Have a gross family unit income, for the 12 months preceding the determination, between 100 percent and 150 percent of the federal poverty guidelines level; and

(d) For out-of-county hospital reimbursement: Have incurred out-of-county hospital bills which would have otherwise qualified for payment under this section and which exceed the applicant’s share of cost.

(e) For in-county hospital reimbursement: Have incurred in-county hospital bills which would have otherwise qualified for payment under this section and which exceed the applicant’s share of cost.

(37)(35) Spend-down Provision Eligible County: A Florida county which was is not at its 10 mill cap on ad valorem taxes as of October 1, 1991, as determined by the Florida Department of Revenue.

(38)(36) State Fiscal Year: July 1 of a given year through June 30 of the subsequent calendar year.

(39) Teaching Hospital: As defined in Section 408.07(45), F.S.

(40)(37) Uncompensated Charity Care: Defined in the Florida Hospital Uniform Reporting System (FHURS) as charity/ uncompensated care – other and charity/uncompensated care – Hill-Burton as reported on work sheet C-3a of the hospitals’ prior year report.

(41)(38) Verification: Confirmation of the accuracy of the information on an application used by the Certifying Agency to determine the applicant’s eligibility through sources other than the self-declaratory statement of the individual originally supplying the information. Verification can be secured by telephone, in written form, or by face-to-face contact. Verification does not require a written document to confirm an applicant’s statement. In the event an employer will not verify the wages paid, the self-declaratory statement provided by the applicant must be accepted as accurate, except in those circumstances where there is substantial evidence to indicate that actual wages are in excess of those stated in the application.

Specific Authority 154.3105 FS. Law Implemented 154.304, 154.306, 154.308, 154.309 FS. History–New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0035, Amended 6-7-00, 12-17-01,                            .

 

59H-1.0045 County Financial Responsibility.

(1) The maximum amount of HCRA funds that a county can allocate for in-county reimbursement is up to ½ of its total HCRA funds.  No county shall have the authority to use out-of-county designated funds to supplement its in-county reimbursement amount above the aforementioned one half. Should a county exceed its designated in-county reimbursement limit, the additional funds must be provided through other funding sources from the county’s budget and the amount exceeded shall not reduce the out-of-county obligation.

(2)(1) A county’s financial responsibility for each of its qualified indigent patients or spend-down provision eligible patients who received treatment in a participating hospital or a regional referral hospital shall not exceed 45 days of inpatient services per county fiscal year, per recipient.  If a qualified indigent patient has at least one day of coverage remaining within his/her 45-day benefit limit at the time of admission, then the eligible days shall be equal to the full length of stay. 

(3)(2) Reimbursement for treatment in a hospital emergency room for emergency medical conditions shall be at the Medicaid outpatient per diem rate and shall be limited to the annual Medicaid reimbursement limits as defined in Rule 59G-4.160, F.A.C.

(4)(3) No county shall be required to pay more than the equivalent of $4 per capita as the maximum county financial responsibility in that county's fiscal year. As detailed in Section 154.306(1), F.S., tThe Aagency shall calculate and certify to each county and hospital by March 1 of each year the maximum county financial responsibility the county shall may be required to pay during the subsequent county fiscal year.

(5)(4) For counties that are spend-down provision eligible counties, the rate of reimbursement to out-of-county participating hospitals shall not be less than 100 % percent of the per diem reimbursement rate in effect for the out-of-county hospital under the Medicaid Pprogram, unless the county and the hospital sign a formal agreement to treat such county's indigent patients at a lower or higher negotiated rate. The county shall provide written notification to the Aagency of the rate negotiated for each hospital and the effective date within 30 calendar days of the date the agreement is signed.  If the due date falls on a weekend or holiday, the deadline is the next business day.

(6)(5) For counties that are not spend-down provision eligible counties, the rate of reimbursement to eligible participating hospitals shall not be less than 80 percent of the per diem reimbursement rate in effect for the out-of-county hospital under the Medicaid Program unless the county and the hospital sign a formal agreement to treat such county’s indigent patients at a lower or higher negotiated rate. The county shall provide written notification to the Aagency of the rate negotiated for each hospital and the effective date within 30 calendar days of the date the agreement is signed. If the due date falls on a weekend or holiday, the deadline is the next business day.

(7)(6) The Aagency will provide semi-annually a list of Medicaid hospital per diem outpatient and inpatient reimbursement rates which would be effective January 1 and July 1, or beginning of the state fiscal year. If a hospital does not have a Medicaid reimbursement rate provided, the Agency shall take an average of other hospitals within the same county to determine the reimbursement rate.  However, the Hhospitals are is responsible for notifying the county of any interim adjustments to its per diem rate. The per diem reimbursement rate utilized at the time of claim adjudication is considered the final rate for that claim. No retroactive per diem rate adjustment is allowed.

(8)(7) Each county shall certify to the agency, within 60 days of the end of the county’s fiscal year, the amount of reimbursement it paid to all out-of-county hospitals. Additionally, should a county reach its maximum county financial responsibility before the end of the fiscal year, the county has 60 days from the date the responsibility has been met to provide the certification to the agency that the responsibility has been met. If the due date falls on a weekend or holiday, the deadline is the next business day.

(9) If there is adequate third party insurance or coverage, the county shall make payment only if such third party insurance or coverage is less tham 80 percent of the reimbursement amount allowed through HCRA.  Joint payment may be made on a claim by both HCRA and such third party insurance or coverage provided the combined total payment does not exceed 100 percent of the reimbursemnt amount allowed through HCRA.

(10)(8) At the end of eEach month, each county must complete a Monthly Caseload and Appeals Report, AHCA Form 3160-0017 Feb. 00, Revised December 1998, documenting caseload activity for the specified month and . Each county must submit this report to the Aagency by the 15th of the month following the end of the reported month, to the address provided on the form. If a county has no caseload activity for any month, the county must file the Caseload and Appeals Report indicating no activity. Timely filing of the report is required. Copies of form may be located in subsection 59H-1.0035(26), F.A.C.

(11)(9) At the end of each quarter, each county must submit complete a Quarterly Financial Report, AHCA Form 3160-0018 Feb. 00, Dec. December 1998, for expenditures and claim activity during a specified quarter and to the agency at the address specified on the report form. Each county must submit this report to the Agency within 30 calendar days from following the end of the reported quarter being reported, to the address provided on the report form. If the due date falls on a weekend or holiday, the deadline is the next business day. Quarters are based on the county’s fiscal year. If a county has no expenditures or activity for any quarter, the county must file the Quarterly Financial Report indicating no activity. Timely filing is required to insure accurate financial information is available to determine if and when the maximum financial responsibility has been met. Copies of form may be located in subsection 59H-1.0035(33), F.A.C.

(12)(10) When the maximum county financial responsibility has been met, the county shall notify the agency, those hospitals with which they have agreements and those hospitals which serve county residents that the maximum county financial responsibility has been met.

(13)(11) In order to be reimbursed, a participating hospital or regional referral hospital must provide documentation to the county that it has met its charity care obligation based on the most recent audited actual experience as reported and certified by the Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis. As defined in Section 154.306, F.S. and subsection 59H-1.0055(5), F.A.C., tThe Aagency will provide, to the hospitals and the counties, annually and more frequently when revised, a list of hospitals meeting their charity care obligation.

(14)(12) Expenditures made under the Shared County and State Health Care Program, Chapter 59H-2, F.A.C., shall not be applied to this program in determining the county’s maximum financial responsibility.

(15)(13) Payment made to a hospital by the county under this chapter for covered services provided to an eligible individual shall be considered as payment in full and the eligible individual shall not be billed, except for the applicant’s share of cost and the cost of any non-covered services.

Specific Authority 154.3105 FS. Law Implemented 154.304(8), 154.306 FS. History–New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0045, Amended 6-7-00,                            .

 

59H-1.0055 Hospital Participation.

(1) The Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis shall determine and certify to the agency, by August 31 July 1 of each year, those hospitals that meet the charity care obligation as defined in subsection 59H-1.0035(10), F.A.C., based on audited actual experience for the hospital’s fiscal year ending within the preceding calendar year. Hospital eligibility is determined annually for the coming county fiscal year. 

(2) Those hospitals that meet the charity care obligation may elect to shall become participating hospitals as defined in subsection 59H-1.0035(27)(29), F.A.C., if the hospitals:

(a) Have a signed formal agreement with a county or counties to treat indigent patients, or

(b) Have at least 2.5 percent of its uncompensated charity care generated by out-of-county patients, as attested by the hospital. For purposes of this section, out-of-county patients shall include non-Florida residents.

(3) Those hospitals that meet the charity care obligation but are not eligible under paragraph 59H-1.0055(2)(a), F.A.C., must provide annually to the Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis by July 31 May 1 the following information in the format prescribed by the Agency Bureau of Certificate of Need/Financial Analysis in order for the Agency Bureau of Certificate of Need/Financial Analysis to determine the amount of out-of-county uncompensated charity care:

(a) Patients by identification number;

(b) City and county of residence for each patient;

(c) Amount of the bill for each patient;

(d) Amount written off as charity care;

(e) Date written off as charity care; and

(f) Criteria accepted by the hospital for verification of residency as provided by a statement signed by the patient or the patient’s legal guardian or designated representative attesting to the patient’s county of residence.

This information shall be for the same period as the period of the hospital’s last fiscal year ending within the preceding calendar year. The Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis shall certify to the Bureau of Managed Health Care, by August 31 July 1 of each year, those hospitals that meet out-of-county requirements as specified in paragraph 59H-1.0055(2)(b), F.A.C.

(4) Teaching hospitals that meet the charity care obligation are eligible for participation as regional referral hospitals.

(5) Subsequent to the initial determination of hospital participation, the Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis shall determine the hospital’s eligibility annually following submission of the hospital’s audited actual experience. The Agency Bureau of Managed Health Care shall annually distribute by September 15, update and annotate a list of participating hospitals and regional referral (or teaching) hospitals to all counties. If, after a hospital has been determined eligible pursuant to subsection 59H-1.0055(3), F.A.C., the Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis finds that the hospital incorrectly reported information used to verify having met its charity care obligations and that based on accurate data the hospital was not eligible to participate, then the hospital’s eligibility shall be rescinded pursuant to the Administrative Procedures Act, Chapter 120, F.S. The hospital shall also repay to the county any amounts paid to the hospital based upon the erroneous certification of eligibility.

(6) The county shall not be liable for payment of treatment of a certified resident who is a qualified indigent patient or spend-down provision eligible patient, until such time as that hospital has documented to the Bureau of Certificate of Need/ Financial Analysis and the Agency’s Financial Analysis Unit Bureau of Certificate of Need/Financial Analysis has determined that the hospital has met its charity care obligations.

(7) The county shall not be liable for payment of treatment of a certified resident who is a qualified indigent patient or spend-down provision eligible patient, until such time as that hospital has documented to the Agency that the hospital has met its obligation to be able to provide the necessary information to the counties required to calculate the rate of reimbursement.

(8)  Timely reimbursement to the counties is required, as applicable, pursuant to subsection 59H-1.010(4).

(9)(7) The county shall notify the Aagency of any hospital which has met the charity care obligation and with which the county has a formal signed agreement, within 30 calendar days of the effective date of the agreement. If the due date falls on a weekend or holiday, the deadline is the next business day.

(10)  The name, title, address, and phone number of the person(s) which shall determine eligibility and process claims on behalf of the hospital shall be provided to the Agency on an annual basis each fiscal year, and when modified. The hospital is responsible for informing the Agency of any changes in this information within 30 calendar days of such change.  The Agency shall provide such information to the counties on an annual and modified basis. In the event the hospitals that meet the charity care obligation do not so designate, the agency shall assume that it is their election to not participate in the HCRA program. 

(11) Each hospital must include a utilization review in its quality improvement plan, as defined in Rule 59A-3.271, F.A.C.

Specific Authority 154.3105 FS. Law Implemented 154.304(4), (8), (10), 154.31 FS. History–New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.005, Amended 6-7-00,                             .

 

59H-1.0065 Covered Services.

(1) Covered services are limited to hospital services as defined in Rules 59G-4.160 and 59G-4.150, F.A.C., and the Medicaid Provider Handbook – Hospital Services, Revised May 2000, incorporated by reference, unless otherwise specified in this rule. The handbook is available from the Medicaid fiscal agent.

(2) The county of residence shall be liable for the cost of emergency services and care or treatment for emergency medical conditions in a hospital emergency room, as defined in Rule 59G-4.160, F.A.C., and the Medicaid Provider Handbook – Hospital Services, Revised May 2000, unless otherwise specified in this rule.

(3) Elective or non-emergency services or admissions require written pre-authorization and pre-approval if the county of residence has established written procedures to authorize and approve admissions to an out-of-county hospital for such services and admissions. The procedures shall include requirements for hospitals to request and obtain written authorization and approval for elective and non-emergency admissions or services.

(4) Elective or non-emergency admissions or services are not covered when a county provides funding for such services and the services are available at a local hospital within the county where the individual resides.

Specific Authority 154.3105 FS. Law Implemented 154.306, 154.31 FS. History–New 3-29-89, Amended 12-24-90, Formerly 10C-26.0065, Amended 6-7-00, 12-9-03,                        .

 

59H-1.008 Determination of a Qualified Indigent Patient.

(1) The county has the primary responsibility for determining eligibility for individuals applying for coverage, using the eligibility determination procedures described in this section. The Aagency shall conduct eligibility determinations only when the county demonstrates to the Aagency that staff are not available. The county shall notify the Aagency of its intent to determine eligibility. The participating hospital or regional referral hospital may elect to provide some of the eligibility documentation to the certifying agency.

(2) The governing board of the county shall designate a person or county agency to be responsible for the administration of the act. The name, title, address, and phone number of the person or county agency, which shall determine eligibility and certify county of residence under the act shall be provided to the Aagency on an annual basis, and when modified. The county is reponsible for informing the Agency of any changes in this information within 30 calendar days of such change.  The Aagency shall provide such information to the participating hospitals and reginal referral hospitals on an annual and modified basis. In the event the county does not so designate, the agency shall determine eligibility and certify residency. 

(3) Hospitals shall screen applicants to determine the availability and adequacy of third party insurance and potential eligibility for Medicaid or other State or Federal governmental programs. Participating hospitals and regional referral hospitals are responsible for initiating the eligibility determination procedures and assisting the applicant in completing the application. The hospital has 30 calendar days from the date of admission or emergency treatment to notify the certifying agency by certified mail of an individual who may qualify or the hospital forfeits its right to reimbursement.  The postage date shall be used to determine such deadline.

(4) Notification shall consist of an application, AHCA form 5220-001 signed by the applicant or the applicant’s designated representative.

(5) In those situations where the applicant is comatose or is physically incapacitated to the extent that an application cannot be completed, and there is no designated representative to complete the application, the hospital may serve as designated representative.

(6) The hospital shall include with the application any documentation available that would assist the certifying agency in determining eligibility or residency, and shall include hospital bills applicable to the applicant’s meeting the applicant’s share of cost. Lack of documentation will not preclude submission of the application nor constitute a reason to delay the submission of the application within proscribed time limits.

(7) The certifying agency has 60 days following receipt of an application from the hospital to determine eligibility. When the applicant provides all required information or verification, the certifying agency determines eligibility for the HCRA program. If for any reason eligibility cannot be determined within 60 days, the hospital shall be notified, in writing, of the reason for the delay. If the due date falls on a weekend or holiday, the deadline is the next business day.

(8)  If the certifying agency determines at any time during the application process, including interviews, that the appilcant must provide additional information or verification, the certifying agency must give the applicant written notice to provide the requested information, allowing 10 calendar days from request or the interview, whichever is later.  If the due date falls on a weekend or holiday, the deadline is the next business day.

(9)(8) The certifying agency shall use gross family income to determine if the family unit’s income is less than or equal to 100 percent of the federal poverty guidelines level or less than or equal to 150 percent of the federal poverty guidelines level for residents of spend-down provision eligible counties. Verification of earnings shall be requested for the 4-week period prior to the date of determination pursuant to Section 154.308(4), F.S. The certifying agency shall require additional income verification for the preceding 12-month period if the income received for the 4-weeks prior to determination is not representative of the family unit’s gross income.

(10)(9) If the family unit’s monthly gross income is more than 100 percent of the federal poverty guidelineslevel and the applicant is a resident of a spend-down provision eligible county, the certifying agency shall use monthly gross family income to determine if the family unit’s income is between 100 percent and 150 percent of the federal poverty guidelines level. Verification of earnings shall be for the one month period prior to the applicant’s date of determination. The certifying agency shall require additional income verification for the preceding 12-month period if the income received for the month prior to the date of determination is not representative of the family unit’s annual gross income.

(11)(10) Verification of income, except as provided in subsection 59H-1.0035(38), F.A.C., may be a written or oral statement that certifies the applicant’s income includes:

(a) A statement from a state or federal agency which attests to the patient's financial status;

(b) A statement from the employer;

(c) Pay stubs for 4 weeks if available or if needed, information for the preceding 12 month period; or

(d) A statement from the source providing unearned income to the applicant or family unit.

(12)(11) The certifying agency shall determine if the applicant’s assets exceed the standards of the asset limits specified in subsection 59H-1.0035(7), F.A.C. The certifying agency shall verify assets but such verification must be completed within 30 days of receipt of the application. If verification is not requested and received within 30 days of receipt of the application, the assets will be accepted as stated in the application unless the certifying agency documents by independent means that assets exceed the limit.

(13)(12) The following shall not be included as assets in the eligibility determination:

(a) One homestead;

(b) Household furnishings;

(c) One automobile in operating condition;

(d) Clothing;

(e) Tools used in employment;

(f) Cemetery plots, crypts, vaults, mausoleums, and urns;

(g) Produce and animals raised for home consumption; and

(h) The income and assets of roomers and boarders. The applicant must verify the person’s status as a roomer or boarder by providing a written statement from the person stating that the applicant is a roomer or boarder, the amount of payment and that the payment is for a room or a room and meals and that the person is not the spouse or partner of the landlord.

(14)(13) The certifying agency may conduct phone or face-to-face interviews with applicants to complete the eligibility review process. The certifying agency may determine eligibility based on documentation submitted by the hospital or applicant without a phone or face-to-face interview, if adequate information is provided to verify income, assets and spend-down provision eligibility.

(15)(14) If the applicant is a resident of a spend-down provision eligible county and the applicant’s gross family income is between 100 percent and 150 percent of the federal poverty guidelines level, the certifying agency shall determine the applicant’s share of cost for the spend-down provision as defined in subsection 59H-1.0035(35), F.A.C. The applicant’s share of cost is the difference between the applicant’s monthly gross family income and 100 percent of the federal poverty guidelines level.

(16)(15) For out-of-county hospital reimbursement, the applicant must have out-of-county hospital bills that exceed the applicant’s share of cost, as defined in subsection 59H-1.0035(35), F.A.C., to be eligible. Allowable out-of-county hospital bills are the out-of-county hospital bill for the date(s) of service indicated on the application, AHCA Form 5220-0001, and all other hospital bills for related services, which would have otherwise qualified for payment under this part, that had been provided during the four weeks prior to the date(s) of service indicated on the application. Follow-up care which occurs within 4-weeks from the date of discharge of a related reimbursed incident shall not require an additional share of cost.

(17)(16) For in-county hospital reimbursement, the applicant must live in a county that uses up to 1/2 of its designated HCRA funds for in-county hospital reimbursement and have in-county hospital bills that exceed the applicant’s share of cost, as defined in subsection 59H-1.0035(34), F.A.C., to be eligible. Allowable in-county hospital bills are the in-county hospital bill for the date(s) of service indicated on the application, AHCA Form 5220-0001, and all other hospital bills for related services, which would have otherwise qualified for payment under this part, that had been provided during the four weeks prior to the date(s) of service indicated on the application. Follow-up care which occurs within 4 weeks from the date of discharge of a related reimbursed incident shall not require an additional share of cost.

(18)(17) To determine if the applicant has met the applicant’s share of cost, the certifying agency shall first determine the amount of reimbursement for which the hospital would have been eligible if no share of cost was involved. To determine the amount of reimbursement for inpatient hospital care, the certifying agency shall multiply the number of approved days by 100 percent of the Medicaid per diem rate or other negotiated rate. The certifying agency shall determine the amount of reimbursement for any outpatient services provided, for which the hospital would have been eligible if no share of cost was involved, based on the Medicaid rate, or other negotiated rate, for each covered service. If the applicant’s share of cost is less than the determined amount of reimbursement, then the applicant has met his share of cost and is eligible for reimbursement through the spend-down provision, within the limitations specified in Rule 59H-1.0045, F.A.C.

(19)(18) The certifying agency shall notify the applicant and the hospital of the disposition of the application using the Notification of Eligibility Form, AHCA Form 5220-0002 within 10 calendar days of the disposition. If the eligibility criteria are met, the applicant is approved for benefits through the HCRA program. A copy of the Nnotification of Eeligibility shall be included with the request for payment submitted by the hospital.

(20)(19) Eligibility shall be retroactive to the date of admission or treatment, as indicated on the application, AHCA Form 5220-0002.

(21)(20) The eligibility determination may be done prior to admission for applicants who expect to be hospitalized for non-emergency or elective services.

(22)(21) The certifying agency shall establish a case record for each individual applying for assistance under the act. The case record shall contain the application, any documentation or evidence used in the determination of eligibility and a copy of any notices issued to the applicant or hospital making the referral.

(23)(22) The certifying agency shall retain all case records for a period of 3 years from the date of the last action taken.

Specific Authority 154.3105 FS. Law Implemented 154.306, 154.308, 154.316 FS. History–New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.008, Amended 6-7-00,                           .

 

59H-1.010 Reimbursement Procedures.

(1) The hospital shall use the universal hospital claim form,   UB 04/CMS-1450 UB 92/HCFA-1450, to submit claims to the county for eligible individuals who received covered hospital care.

(2) Each county shall designate an office or agency that will pay claims.  The name, title, address, and phone number of the person or county agency, which shall process claims under the act shall be provided to the Agency on an annual basis, and when modified. The county is reponsible for informing the Agency of any changes in this information within 30 calendar days of such change.  The Agency shall provide such information to the participating hospitals and regional referral hospitals on an annual and modified basis.

(3) The hospital shall submit the completed claim and a copy of the notification of eligibility to the resident county office designated to pay claims within 6 months of the date of the notice of eligibility. Failure to receive a claim within 6 months may result in rejection of the claim at the option of the county.

(4) The county shall reimburse the hospital within 90 calendar days of receipt of a claim, unless the claim is disputed under the provisions of Chapter 120, F.S. In cases where the patient becomes eligible for third party payment, disability benefits or other state or federal benefits, the hospital shall reimburse the county for any overpayment by the county within 60 calendar days of receipt of such payment from any other source.  In cases where the hospital has received overpayment on a claim(s), the hospital shall reimburse the county for any overpayment within 60 calendar days of receipt of such notification.  If the due date falls on a weekend or holiday, the reimbursement deadline is the next business day.  Overpayment is an adjustment of charges, including credit balance resulting from a payment made by an insurance carrier or another responsible party, duplicate payment, reimbursement calculation error (as examined by one or more individuals with either the county, hospital or Agency and determined to have been paid in error based on the review of the documentation supporting the claim), or misapplied charges or credits. 

(5) In cases where payment is made to a hospital for a spend-down provision eligible applicant and no third party payor or other government program is involved, the total payment to the hospital shall not exceed the Medicaid reimbursement rate, or other negotiated rate, minus the applicant’s share of cost.

(6) The county shall provide the agency, if requested, a copy of the claim for which payment is made or denied, indicating disposition and date.

Specific Authority 154.3105 FS. Law Implemented 154.306, 154.314 FS. History–New 3-29-89, Amended 2-24-92, Formerly 10C-26.010, Amended 6-7-00,                            .

 

59H-1.015 Administrative Hearings, Applicant’s Rights and Responsibilities.

(1) An individual, his designated representative or Tthe hospital may appeal any decision made by the certifying agency concerning an applicant’s his eligibility under the Act. A fair hearing shall be conducted in accordance with Chapter 120, F.S.

(2) Applicants, recipients and or designated representatives are responsible for keeping appointments as required by the certifying agency, assuming the responsibility to assist in the determination of eligibility and providing the certifying agency with sources of information, documentation and verification concerning the individual’s affairs related to the eligibility determination. Failure to keep appointments do so without good cause, may result in a rejection of the application. The certifying agency makes the decision of whether or not to grant an extension.

(3) An applicant or designated representative of the applicant assumes the responsibility for providing accurate information on which to determine eligibility. If the applicant or designated representative does not provide required verifications or information by the deadline date specified in Rule 59H-1.008, F.A.C, the application will be denied.

(4) The applicant or designated representative is responsible to repay any amount paid on the applicant’s behalf if it is later determined that fraud was committed or intentionally incorrect information was provided by the applicant or designated representative that resulted in an inappropriate eligibility determination.

Specific Authority 154.3105 FS. Law Implemented 154.312 FS. History–New 3-29-89, Formerly 10C-26.015, Amended_____      .

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Kirsten Jacobson

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek, Secretary, Agency for Health Care Administration

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: March 22, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 9, 2014