Definitions, County Financial Responsibility, Hospital Participation, Covered Services, Determination of a Qualified Indigent Patient, Reimbursement Procedures, Administrative Hearings, Applicant's Rights and Responsibilities
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
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 42 No. 63, March 31, 2016 issue of the Florida Administrative Register.
59H-1.0035 Definitions.
The following words and phrases shall have the following meanings for the purpose of this rule chapter.
(1) No change.
(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 outpatient per diem rate or inpatient reimbursement rate allowed 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 hospital’s outpatient per diem rate or inpatient reimbursement rate allowed payment method utilizing DRG for Florida Medicaid.
(3) through (4) No change.
(5) Application: The Health Care Assistance Application, AHCA Form 5220-0001, February 2016, used to apply for coverage for hospital services under the Act. 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.
(6) through (10) No change.
(11) Claim: The universal hospital billing form, UB 04/CMS-1450. Only one original claim form may be used for each eligible individual. All information must be in black type with no written modifications. The claim shall be completed pursuant to subsection 59H-1.0065(1) F.A.C. A copy of the form is provided in the HCRA Handbook may be obtained from the district Medicaid office.
(12) through (13) No change.
(14) Designated Representative: An individual who has personal knowledge of the applicant’s circumstances and is authorized to act responsibly on behalf of an applicant 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) through (19) No change.
(20) HCRA Handbook: The Florida Health Care Responsibility Act (Act, HCRA, or Program) Handbook, February 2016, 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. 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; and the UB 04/CMS-1450 Claim.
(21) through (25) No change.
(26) Monthly Caseload and Appeals Report: The form, Monthly Caseload and Appeals Report, AHCA Form 3160-0017, February 2016, 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 each county’s caseload activity on applications and appeals. Copies of the report form may be obtained from the HCRA Handbook.
(27) Notification of Eligibility: The form, Notification of Eligibility, AHCA Form 5220-0002, February 2016, used by the Certifying Agency to notify hospitals of the eligibility determination of an application. Copies of the notification form may be obtained from the HCRA Handbook.
(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, meaning that a hospital stay may occur over the course of two calendar days and still be less than a 24-hour period. Only one day’s services are billable on one outpatient claim.
(29) through (30) No change.
(31) 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) No change.
(33) Quarterly Financial Report: The form, Quarterly Financial Report, AHCA Form 3160-0018, February 2016, 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 each county’s expenditures and claim activity. Copies of the report form may be obtained from the HCRA Handbook.
(34) through (35) No change.
(36) 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(32)(33), 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 poverty guidelines; and
(d) Have incurred hospital bills which would have otherwise qualified for payment under this section and which exceed the applicant’s share of cost.
(37) through (41) No change.
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) No change.
(2) 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 shall not exceed 45 days of inpatient services per county fiscal year, per applicant 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) Reimbursement for treatment in a hospital emergency room for emergency medical conditions shall be at the Medicaid outpatient reimbursement per diem rate and shall be limited to the annual Medicaid reimbursement limits as defined in Rule 59G-4.160, F.A.C.
(4) through (6) No change.
(7) The Agency will provide annually a list of Medicaid hospital outpatient and inpatient reimbursement rates which would be effective 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. Hospitals are responsible for notifying the county of any interim adjustments to its reimbursement per diem rate under the Medicaid Program. The 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) through (9) No change.
(10) At the end of each month, each county must complete a Monthly Caseload and Appeals Report, AHCA Form 3160-0017 December 1998, documenting caseload activity for the specified month and submit this report to the Agency 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 the form may be located as provided in subsection 59H-1.0035(26), F.A.C.
(11) At the end of each quarter, each county must complete a Quarterly Financial Report, AHCA Form 3160-0018 December 1998, for expenditures and claim activity during a specified quarter and submit this report to the Agency within 30 calendar days following the end of the reported quarter, 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 the form may be located as provided in subsection 59H-1.0035(33), F.A.C.
(12) When the maximum county financial responsibility has been met, the county shall notify the Aagency, those hospitals with which they have agreements and those hospitals which serve county residents that the maximum county financial responsibility has been met.
(13) In order to be reimbursed, a participating hospital must have 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. As defined in Section 154.306, F.S. and subsection 59H-1.0055(5), F.A.C., the Agency will provide, to the hospitals and the counties, annually and more frequently when revised, a list of hospitals meeting their charity care obligation.
(14) 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.
(14)(15) No change.
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) through (10) No change.
(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 Florida Medicaid Provider Handbook – Hospital Services Coverage and Limitations Handbook, incorporated by reference in Rule 59G-4.160, F.A.C. unless otherwise specified in this rule. Copies of the handbook may be obtained at https://www.flrules.org/Gateway/reference.asp?No=Ref-01232 and from the Agency’s website at http://portal.flmmis.com/flpublic/default.aspx. Select Provider Services, then Support, and then Handbooks. 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 Florida Medicaid Provider Handbook – Hospital Services Coverage and Limitations Handbook, unless otherwise specified in this rule.
(3) through (4) No change.
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 of residence has the primary responsibility for determining eligibility for individuals applying for coverage, using the eligibility determination procedures described in this section. The Agency shall conduct eligibility determinations only when the county demonstrates to the Agency that staff are not available. The county shall notify the Agency of its intent to determine eligibility. The participating 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 Aact. The name, title, address, and phone number of the person or county agency, which shall determine eligibility and certify county of residence under the Aact shall be provided to the Agency on an annual basis, and when modified. The county 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 participating hospitals and reginal referral hospitals on an annual and modified basis.
(3) through (7) No change.
(8) If the certifying agency determines at any time during the application process, including interviews, that the applicant must provide additional information or verification, the certifying agency must give the applicant written notice to provide the requested information, allowing at least 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) through (10) No change.
(11) Verification of income, except as provided in subsection 59H-1.0035(41)(38), F.A.C., may be a written or oral statement that certifies the applicant’s income includes:
(a) through (d) no change.
(12) through (14) No change.
(15) 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 poverty guidelines, the certifying agency shall determine the applicant’s share of cost for the spend-down provision as defined in subsection 59H-1.0035(37)(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 poverty guidelines.
(16) No change.
(17) 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(35)(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 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) through (19) No change.
(20) Eligibility shall be retroactive to the date of admission or treatment, as indicated on the application, AHCA Form 5220-0002.
(21) No change.
(22) The certifying agency shall establish a case record for each individual applying for assistance under the Act 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) No change.
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-1.015 Administrative Hearings, Applicant’s Rights and Responsibilities.
(1) No change.
(2) Applicants, 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 do so shall 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) through (4) No change.
Specific Authority 154.3105 FS. Law Implemented 154.312 FS. History–New 3-29-89, Formerly 10C-26.015, Amended_____ .
The following changes have been made to the HCRA Handbook incorporated by reference in Rule 59H-1.0035, F.A.C.:
Appendix C:
Footer added to both pages of Quarterly Financial Report, AHCA Form 3160-0018, February 2016.
Appendix D and H:
Clarified that form is for informational purposes only.
Appendix E and I:
Clarified that form represents sample submission.
Appendix F, Notification of Eligibility, AHCA Form 5220-0002, February 2016:
Removed any references to Rules 59H-2.003 – 2.011, F.A.C. and added certificate of service to footer.
