RULE NO: RULE TITLE
59G-6.030: Payment Methodology for Outpatient Hospital Services
PURPOSE AND EFFECT: The proposed rule development incorporates changes to the Florida Title XIX Outpatient Hospital Reimbursement Plan in accordance with Senate Bill 2600, 2009-2010 General Appropriations Act, Specific Appropriation 193.
1. The Agency may amend its current facility fees and physician services to allow for payments to hospitals providing primary care to low-income individuals and participating in the Primary Care Disproportionate Share Hospital (DSH) program in Fiscal Year 2003-2004 provided such hospital implements an emergency room diversion program so that non-emergent patients are triaged to lesser acute settings; or a public hospital assumed the fiscal and operating responsibilities for one or more primary care centers previously operated by the Florida Department of Health or the local county government. Any payments made to qualifying hospitals because of this change shall be contingent on the state share being provided through grants and donations from counties, local governments, public entities, or taxing districts, and federal matching funds. This provision shall be contingent upon federal approval of a state plan amendment.
2. The Agency shall implement a recurring methodology in the Title XIX Outpatient Hospital Reimbursement Plan to achieve a $10,403,322 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.
3. Elimination of the outpatient reimbursement ceilings for hospitals whose charity care and Medicaid days as a percentage of total adjusted hospital days equals or exceeds 11 percent. For any public hospital or any leased public hospital found to have sovereign immunity or hospital with graduate medical education positions that does not qualify for the elimination of the outpatient ceilings under this provision of proviso or any other proviso listed, such hospitals shall be exempt from the outpatient reimbursement ceilings contingent on the public hospital or local governmental entity providing the required state match. The agency shall use the average of the 2003, 2004 and 2005 audited DSH data available as of March 1, 2009. 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 2003, 2004 and 2005 that are available.
4. Elimination of the outpatient reimbursement ceilings for hospitals that have a minimum of ten licensed Level II Neonatal Intensive Care Beds and are located in Trauma Services Area 2.
5. Elimination of the outpatient reimbursement ceilings 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, 2009 or become a designated or provisional trauma center during Fiscal Year 2009-2010. 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 2003, 2004 and 2005 audited DSH data available as of March 1, 2009. 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 2003, 2004 and 2005 that are available. Funds provided for the elimination of hospital outpatient ceilings in Specific Appropriation 193 are contingent upon the state share being provided through grants and donations from state, county or other governmental funds. The agency shall submit a revised hospital outpatient reimbursement plan to the Legislative Budget Commission for approval if the state share is not available to fund the removal of hospital outpatient ceilings or if the Centers for Medicare and Medicaid Services does not approve amendments to the Medicaid Hospital Outpatient Reimbursement Plan to eliminate the reimbursement ceilings for certain hospitals.
6. $18,445,845 is provided to buy back the Medicaid trend adjustment that is being applied against the Medicaid outpatient rates for the following three categories of hospitals:
• $6,711,233 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: $2,762,760 is for Jackson Memorial Hospital; $803,934 is for hospitals in Broward Health; $1,211,814 is for hospitals in the Memorial Healthcare System; and $795,574 to Shands Jacksonville and $1,137,151 to Shands Gainesville. In the event that the above amounts exceed the amount of the Medicaid trend adjustment applied to each hospital, then the excess funds will be used to buy back other Medicaid reductions in the outpatient rate.
• $5,985,074 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 that the above amounts exceed the amount of the Medicaid trend adjustment applied to each hospital, then the excess funds will be used to buy back other Medicaid reductions in the outpatient rate.
• $5,749,538 shall be used for the third category to buy back the Medicaid trend adjustment that is being applied against the Medicaid outpatient rates for rural hospitals. 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 buy back other Medicaid reductions in the outpatient rate for those individual hospitals. For this section of proviso the agency shall use the average of 2003, 2004 and 2005 audited DSH data available as of March 1, 2009. 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 2003, 2004 and 2005 that are available.
7. Provided for public hospitals, including any leased public hospital found to have sovereign immunity, teaching hospitals as defined in s. 408.07 (45) or 395.805, Florida Statutes, which have seventy or more full-time equivalent resident physicians and designated trauma hospitals 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 payments under this proviso are contingent on the state share being provided through grants and donations from state, county or other governmental funds. This section of proviso does not include the buy back of the Medicaid outpatient trend adjustment applied to the individual state mental health hospitals.
8. Unrelated to SB 2600, the Agency is deleting the phrase “Upon request for a copy of any cost report, the hospital involved shall be notified as to the party making the request and the information requested. Unless prohibited by a court of competent jurisdiction, the cost report shall be released to the requestor 15 days from receipt of the request by AHCA” from section A.J. of the Title XIX Outpatient Hospital Plan.
9. Unrelated to SB 2600, The Agency is removing the “October 1, 2003” date from the provision related to the acceptance of audited cost reports.
SUBJECT AREA TO BE ADDRESSED: July 1, 2009 Outpatient Hospital reimbursement rates and cost report issues.
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 22, 2009, 10:00 a.m. – 11:00 a.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Conference Room C, Building 3, Tallahassee, Florida
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 2149-A, Tallahassee, Florida 32308, (850)414-2759 or stephense@ahca.myflorida.com

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