The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code, is to update forms required by Florida Medicaid that impact multiple services.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-1.045Medicaid Forms

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-1.045, Florida Administrative Code, is to update forms required by Florida Medicaid that impact multiple services.

SUMMARY: The amendment updates existing forms and incorporates by reference additional forms that are specified in various Florida Medicaid coverage policies.

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: 409.902, 409.905, 409.912 FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN THE FAR.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Laura Risech, 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 5:00 p.m. February 15, 2017. 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-1.045Medicaid Forms.

The following forms are incorporated by reference and are used either by other state agencies or providers rendering Florida Medicaid services to recipients. The forms are available from the Agency for Health Care Administration’s website at http://ahca.myflorida.com/Medicaid/review/index.shtml.

(1) Medical Certification for Medicaid Long-term Care Services and Patient Transfer Form, AHCA Form 5000-3008, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07012.

(2) Pre-Admission Screen and Resident Review (PASRR) Level I Screen for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A, October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05827.

(3) Pre-Admission Screening and Resident Review (PASRR) Resident Review (RR) – Evaluation Request for a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID), AHCA MedServ Form 004 Part A1, October 2015, http://www.flrules.org/Gateway/reference.asp?No=Ref-05828.

(2)(4) State of Florida Abortion Certification Form, AHCA MedServ Form 011, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07013.

(3)(5) State of Florida Exception to Hysterectomy Acknowledgment Requirement, ETA-5001, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07014.

(4)(6) State of Florida Hysterectomy Acknowledgment Form, HAF-5000, June 2016, http://www.flrules.org/Gateway/reference.asp?No=Ref-07015.

(5) The United States Department of Health and Human Services’ Consent for Sterilization Form - HHS-687 (10/12), http://www.flrules.org/Gateway/reference.asp?No=Ref-07025.

(6)(7) Unborn Activation Form, AHCA Form 5240-006,(updated effective date of form) , http://www.flrules.org/Gateway/reference.asp?[ DOS Ref number-place holder].

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.912 FS. History–New 9-28-15, Amended 7-11-16,_____.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Laura Risech

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

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: January 17, 2017

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: September 23, 2016