The purpose of Rule 59G-6.031, Florida Administrative Code (F.A.C.), is to codify Florida Medicaid’s reimbursement methodology for hospital outpatient services and ambulatory surgical centers.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-6.031Enhanced Ambulatory Patient Grouping Reimbursement Methodology for Hospital Outpatient Services

PURPOSE AND EFFECT: The purpose of Rule 59G-6.031, Florida Administrative Code (F.A.C.), is to codify Florida Medicaid’s reimbursement methodology for hospital outpatient services and ambulatory surgical centers.

SUMMARY: The rule specifies outpatient prospective payment systems as required in sections 409.905(6)(b) and 409.908(5), F.S.

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: 409.905, 409.908, 409.913 FS.

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

DATE AND TIME: August 28, 2018, 3:30 p.m. to 4:00 p.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: Rydell Samuel. 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: Rydell Samuel, Bureau of Medicaid Program Finance, 2727 Mahan Drive, Mail Stop 23, 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 August 29, 2018. 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-6.031 Enhanced Ambulatory Patient Grouping Reimbursement Methodology for Hospital Outpatient Services and Ambulatory Surgical Centers.

(1) This rule applies to all hospitals and ambulatory surgical centers (ASC) rendering Florida Medicaidoutpatient hospital services to recipients, in accordance with Rules 59G-4.160 and 59G-4.020, Florida Administrative Code, (F.A.C.), respectively.

(2) Definitions.

(a) Automatic Rate Enhancement – An additional fee applied to each payable claim line.

(b) Base Rate – An amount calculated using 12 months of historical claims data.

(c) Bundled EAPG Payment – A single payment applied to one claim line that includes reimbursement for services reported on multiple claim lines.

(d) Charge Cap – A limitation that ensures the Medicaid-allowed amount does not exceed the submitted charges on either individual service line(s), or overall for the entire outpatient claim.

(e) Crossover Claim – Provider claim for services provided to recipients who are eligible for Medicare and Medicaid services, or who have other third-party insurance.

(f) Discounting Claim Line – A service line on a claim where the payment is reduced.

(g) Enhanced Ambulatory Patient Groups (EAPG) – A product of 3M Health Information Systems (HIS) that categorizes outpatient services and procedures into groups for payment based on clinical information present on an outpatient claim.

(h) EAPG Code - Proprietary number developed by 3M HIS to indicate a specific grouping of services.

(i) EAPG Methodology - Reimbursement system that provides an all-inclusive rate for all services and items furnished during an outpatient visit, unless otherwise specified. The methodology categorizes the amount and type of services provided during an outpatient visit and groups together procedures, medications, materials, and patient factors that share similar characteristics and resource utilization. Each category is assigned an EAPG code. Each EAPG code is assigned a relative weight (which may equal zero) that is used to calculate payment.

(j) Florida Medicaid Outpatient Charges – The usual and customary charges for outpatient services covered by the Florida Medicaid program for a hospital or an ASC.

(k) General Hospital – As defined in section 395.002(10), Florida Statutes (F.S.).

(l) High Medicaid Outpatient Utilization Hospital - A hospital that renders 55 percent or more of its total annual outpatient services to Florida Medicaid recipients.

(m) Payment Adjustment Factor – A multiplier used to package and consolidate payment for similar services; or, to discount services if the services are determined to be clinically similar to other services on the claim.

(n) Policy Adjustor - Numerical multipliers included in the EAPG claim service line payment calculation that increase or decrease payments to categories of services, categories of providers, or both.

(o) Provider Rate Worksheets – A list of the EAPG base rates and automatic rate enhancements for each hospital and ASC.

(p) Relative Weights – National average values calculated by 3M HIS which identify the relative amount of resources utilized to perform the services mapped to the EAPG code.

(q) Rural Hospital – As defined in section 395.602(2), F.S.

(r) Service Line Payment – A calculation used to determine individual claim line reimbursement.

(s) Service Line Procedure Code – The assigned Common Procedure Terminology© code included on a claim line.

(3) Reimbursement. Effective July 1, 2017, the Agency for Health Care Administration (AHCA) will reimburse for Florida Medicaid outpatient hospital services rendered by hospital and ASC providers using the EAPG payment methodology in accordance with section 409.905, F.S.

(4) Reimbursement Methodology.

(a) EAPG Payment Calculation. The calculation is as follows: [(Base Rate * EAPG Relative Weight * Policy Adjustor * Payment Adjustment Factor) (up to the $1,500 recipient annual benefit limit, when applicable)] + Automatic Rate Enhancement.

(b) Base Rate. AHCA will establish base rates. The base rates for dates of service beginning July 1, 2017 through March 31, 2018 are incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/medicaid/cost_reim/xls/Provider_EAPG_Rate_Worksheet_FY_2017-2018_Effective_July-1-2017_2018-01.xlsx and at [DOS place holder Ref-_______]. The base rates for dates of service beginning April 1, 2018 through June 30, 2018 are incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/medicaid/cost_reim/xls/Provider_EAPG_Rate_Worksheet_FY_ 2017-2018_Effective_April-1-2018.xlsx and at [DOS place holder Ref-_______]. The base rates for dates of service beginning July 1, 2018 are incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/medicaid/cost_reim/xls/Provider_EAPG_Rate_Worksheet_FY _2017-2018_Effective_July-1-2018.xlsx and at [DOS place holder Ref-_______].

(c) EAPG Relative Weight. AHCA will use 3M HIS relative weights incorporated by reference and available on the AHCA website at http://ahca.myflorida.com/medicaid/cost_reim/xls/EAPG_Rate_Worksheet_2017-2018_Effective_2017-07-01.xlsx and at [DOS place holder Ref-_______]. AHCA will use the service line procedure code to determine the EAPG code and relative weight, except in claims for evaluation and management services without another significant procedure, wherein AHCA will use the recipient’s primary diagnosis to determine the EAPG code and relative weight.

(d) Policy Adjustor. AHCA will only include a provider policy adjustor in the EAPG payment for rural hospitals and high Florida Medicaid outpatient utilization hospitals.

(e) Payment Adjustment Factor. AHCA will establish the Payment Adjustment Factor(s) as follows:

1. The Payment Adjustment Factor will be 1.0 for claim service lines that pay in full.

2. The Payment Adjustment Factor will be zero for bundled lines.

3. The Payment Adjustment Factor will be 0.50 on discounting claim lines, except for bilateral procedures.

4. The Payment Adjustment Factor will be 1.50 for bilateral procedures.

(f) Automatic Rate Enhancements. AHCA will apply an automatic rate enhancement to payable claim lines for outpatient hospitals listed in the provider rate worksheet incorporated by reference and available on the AHCA Web site at: http://ahca.myflorida.com/medicaid/cost_reim/hospital_rates.shtml and at [DOS place holder Ref-_______].

1. For each hospital receiving automatic rate enhancements, AHCA will calculate a per-payable service-line payment amount by dividing the annual appropriation by the number of Florida Medicaid outpatient payable service lines in the base year.

2. AHCA will apply an automatic rate enhancement payment as follows:

a. To claim service lines that receive a bundled EAPG payment.

b. When adjudicated after a recipient reaches his or her annual hospital outpatient benefit limit with

claim service lines that are paid $0.00 and have a status of paid.

3. AHCA will apply an automatic rate enhancement payment of $0.00 to claim service lines when claim services lines are denied.

(g) Budget Neutrality. AHCA will reconcile the EAPG parameters to comply with budget neutrality requirements.

(h) Terminated Procedures. AHCA will reimburse providers for procedures that are terminated prior to the administration of anesthesia at 50% of the rate.

(i) Charge Cap. AHCA will not apply a charge cap to services reimbursed under the EAPG payment methodology.

(5) Exclusion. AHCA will not apply the EAPG reimbursement methodology to reimburse the following:

1. Services covered under the transplant global fee in accordance with Rule 59G-4.150, F.A.C.

2. Vagus nerve stimulator device payments.

3. Newborn hearing screening.

(6) Cost Settlement. AHCA will not subject hospitals and ASCs reimbursed using the EAPG payment methodology to retrospective cost settlement.

(7) Crossover Pricing. For hospital outpatient crossover claims, AHCA will determine the Medicaid allowed amount using the EAPG pricing methodology.

Rulemaking Authority 409.919 FS. Law Implemented 409.905, 409.908, 409.913 FS. History–

New_______.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Rydell Samuel

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Justin M. Senior

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: July 30, 2018

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: July 7, 2017