RULE NO: RULE TITLE
59G-6.030: Payment Methodology for Outpatient Hospital Services
PURPOSE AND EFFECT: To incorporate changes to the Florida Title XIX Outpatient Hospital Reimbursement Plan payment methodology, effective July 1, 2008, in accordance with House Bill 5001, 2008-09 General Appropriations Act, Specific Appropriation 211 and House Bill 5085, Section 5, which amended Section 409.908(23), Florida Statutes.
SUBJECT AREA TO BE ADDRESSED: 1. As a result of implementing a reduction in outpatient hospital reimbursement rates, the Agency shall implement a recurring methodology in the Title XIX Outpatient Hospital Reimbursement Plan to achieve a $36,403,451 rate reduction. In establishing rates through the normal process, prior to including this reduction, if the unit cost is equal to or less than the unit cost used in establishing the budget, then no additional reduction in rates is necessary. In establishing rates through the normal process, prior to including this reduction, if the unit cost is greater than the unit cost used in establishing the budget, then rates shall be reduced by an amount required to achieve this reduction, but shall not be reduced below the unit cost used in establishing the budget.
2. The Agency shall establish rates at a level that ensures no increase in statewide expenditures resulting from a change in unit costs for two fiscal years effective July 1, 2009. Reimbursement rates for the two fiscal years shall be as provided in the General Appropriations Act.
3. Outpatient reimbursement ceilings for hospitals will be eliminated for those hospitals whose charity care and Medicaid days as a percentage of total adjusted hospital days equals or exceeds 11 percent. The Agency shall use the average of the 2002, 2003 and 2004 audited DSH data available as of March 1, 2008. In the event the Agency does not have the prescribed three years of audited DSH data for a hospital, the Agency shall use the average of the audited DSH data for 2002, 2003, and 2004 that are available.
4. Outpatient reimbursement ceilings will be eliminated for hospitals that have a minimum of ten licensed Level II Neonatal Intensive Care Beds and are located in Trauma Services Area 2.
5. Outpatient hospital reimbursement ceilings will be eliminated for hospitals whose Medicaid days, as a percentage of total hospital days, exceed 7.3 percent, and are designated or provisional trauma centers. This provision shall apply to all hospitals that are designated or provisional trauma centers on July 1, 2008, or become a designated or provisional trauma center during Fiscal Year 2008-2009.
Included in these funds are the annualized amounts to offset the reductions taken against certified trauma centers as identified in Section 13, Chapter 2007-326, Laws of Florida. The Agency shall use the average of the 2002, 2003, and 2004 audited DSH data available as of March 1, 2008. In the event the Agency does not have the prescribed three years of audited DSH data for a hospital, the Agency shall use the average of the audited DSH data for 2002, 2003 and 2004 that are available.
6. A buy back provision for the Medicaid trend adjustment will be applied against the Medicaid outpatient rates for the following three categories of hospitals. Of these funds $3,515,024 is provided to the first category of hospitals, which are those hospitals that are part of a system that operate a provider service network in the following manner: $831,338 is for hospitals in Broward Health; $823,362 is for hospitals in the Memorial Healthcare System; and $601,863 to Shands Jacksonville and $1,258,461 to Shands Gainesville. In the event that the above amounts exceed the amount of the Medicaid trend adjustment applied to each hospital, the excess funds will be used to buy back other Medicaid reductions in the outpatient rate. Of the above funds, $5,203,232 shall be used for the second category to buy back the Medicaid trend adjustment that is being applied against the Medicaid outpatient rates for those hospitals that are licensed as a children’s specialty hospital and whose Medicaid days plus charity care days divided by total adjusted patient days equals or exceeds 30 percent. In the event the above amounts exceed the amount of the Medicaid trend adjustment applied to each hospital, the excess funds will be used to buy back other Medicaid reductions in the inpatient rate. Of the above funds, $2,170,197 shall be used for the third category to buy back the additional Medicaid trend adjustment that is being applied to rural hospitals under Specific Appropriation 211 for Fiscal Year 2008-2009. In the event that the funds under this category exceed the amount of the Medicaid trend adjustment, then any excess funds will be used to buyback other Medicaid reductions in the outpatient rate for those individual hospitals. For this provision the Agency shall use the average of 2002, 2003 and 2004 audited DSH data available as of March 1, 2008. In the event the Agency does not have the prescribed three years of audited DSH data for a hospital, the Agency shall use the average of the audited DSH data for 2002, 2003 and 2004 that are available.
7. A buy back provision will be applied for teaching hospitals as defined in Section 408.07(45) or 395.805, Florida Statutes, which have 70 or more full-time equivalent resident physicians and those hospitals whose Medicaid and charity care days divided by total adjusted days exceeds 25 percent to buy back the Medicaid outpatient trend adjustment applied to their individual hospital rates and other Medicaid reductions to their outpatient rates up to actual Medicaid outpatient cost. The Agency shall use the 2002, 2003 and 2004 audited DSH data available as of March 1, 2008. In the event the Agency does not have the prescribed three years of audited DSH data for a hospital, the Agency shall use the average of the audited DSH data for 2002, 2003 and 2004 that are available.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.908 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: July 24, 2008, 10:00 a.m. – 11:00 a.m.
PLACE: 2727 Mahan Drive, Conference Room D, Building 3, Tallahassee, Florida 32301
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Edwin Stephens, Medicaid Program Analysis, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Room 2149A, Tallahassee, Florida 32308, (850)414-2759 or stephense@ahca.myflorida.com

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS NOT AVAILABLE.