59G-6.030: Payment Methodology for Outpatient Hospital Services
PURPOSE AND EFFECT: 1. 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, such hospitals shall be exempt from the outpatient reimbursement ceilings. 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. Any hospital that was exempt from the outpatient reimbursement ceiling in the prior state fiscal year, due to their charity care and Medicaid days as a percentage to total adjusted hospital days equaling or exceeding 11 percent, but no longer meet the 11 percent threshold, because of updated audited DSH data shall remain exempt from the outpatient reimbursement ceilings for a period of two years.
2. 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.
3. Elimination 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, 2010 or become a designated or provisional trauma center during Fiscal Year 2010-2011. 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.
4. Revisions to the outpatient revenue codes and the addition of a reference to the Florida Medicaid Hospital Services Coverage and Limitations Handbook incorporated by reference in Rule 59G-4.160, F.A.C.
5. $12,226,583 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:
• $3,372,389 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:
$570,978 is for Jackson Memorial Hospital;
$458,668 is for hospitals in Broward Health;
$840,958 is for hospitals in the Memorial Healthcare System;
$256,166 to Shands Jacksonville and
$1,245,619 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.
$4,221,468 shall be used for the second category of hospitals 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.
$4,632,726 shall be used for the third category of hospitals 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.
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.
6. $66,317,949 is provided for public hospitals, including any leased public hospital found to have sovereign immunity, teaching hospitals as defined in Section 408.07(45) or 395.805, Florida Statutes, which have seventy or more full-time equivalent resident physicians, hospitals with graduate medical education positions that do not otherwise qualify, 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.
7.a) Hospitals may 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.; and
b) $15,000,000 is provided for exemptions from outpatient reimbursement limitations for any hospital that has local funds available for intergovernmental transfers, not elsewhere qualifying for an exemption. The agency shall not include the funds described in this paragraph for the buy back of reductions to outpatient hospital rates in the calculation of capitation rates for Health Maintenance Organizations unless the nonfederal share is provided through grants and donations from state, county or other governmental funds.
8. Clarifying the definitions of cost report acceptance and due dates.
9. AHCA reserves the right to submit any provider found to be out of compliance with any of the policies and procedures regarding cost reports to the Bureau of Medicaid Program Integrity for investigations.
10. Providers are subject to sanctions pursuant to Section 409.913(15)(c), F.S., for late cost reports. A cost report is late if it is not received by AHCA, Bureau of Medicaid Program Analysis, on the first cost report acceptance cut-off date after the cost report due date.
SUMMARY: The proposed rule effective July 1, 2010, brings the Title XIX Outpatient Hospital Reimbursement Plan into compliance with House Bill 5001, 2010-11 General Appropriations Act, Specific Appropriation 194, and Section 409.913(15)(c), F.S.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: The Agency has determined that this rule will not have an impact on small business. A SERC has not been prepared by the Agency.
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.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.908 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: December 1, 2010, 10:00 a.m. – 11:00 a.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room C, Tallahassee, Florida 32308
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Edwin Stephens, Medicaid Program Analysis, 2727 Mahan Drive, Mail Stop 21, Tallahassee, Florida 32308, (850)412-4077 or edwin.stephens@ahca.myflorida.com
THE FULL TEXT OF THE PROPOSED RULE IS:
59G-6.030 Payment Methodology for
Reimbursement to participating outpatient hospitals for services provided shall be in accordance with the Florida Title XIX Outpatient Hospital Reimbursement Plan, Version XXI XX Effective date: July 1, 2010 July 1, 2009, and incorporated herein by reference. A copy of the Plan as revised may be obtained by writing to the Office of the Deputy Secretary for Medicaid, Agency for Health Care Administration,