Current through Reg. 50, No. 187; September 24, 2024
(1)
Purpose. This rule specifies requirements that apply to all providers rendering
Florida Medicaid services to recipients.
(2) Billing the Recipient. Providers must
inform a recipient of his or her responsibility to pay for services that are
not covered by Florida Medicaid, and document in the recipient's file that the
recipient was informed of his or her liability, prior to rendering each
service.
(a) Providers may seek reimbursement
from a recipient under the following circumstances:
1. The recipient is not eligible for Florida
Medicaid on the date of service.
2.
The service rendered is not covered by Florida Medicaid, if the provider seeks
reimbursement from all patients for the specific service.
3. The provider verifies that the recipient
has exceeded the Florida Medicaid coverage.
4. The recipient is enrolled in a Florida
Medicaid managed care plan (plan) and is informed that:
a. The plan denies authorization for the
service.
b. The treating provider
is not in the plan's provider network (with the exception of emergency
services).
(b)
Providers may not seek reimbursement from recipients for missed
appointments.
(c) Providers may not
seek reimbursement from the recipient if the provider fails to bill Florida
Medicaid correctly and in a timely manner. Providers who submit a claim to
Florida Medicaid for reimbursement of a covered service whether the claim has
been approved, partially approved, or denied, may not:
1. Seek reimbursement from the recipient, the
recipient's relatives, or any person, or persons, acting as the recipient's
designated representative.
2. File
a lien against the recipient, the recipient's parent, legal guardian, or
estate.
3. Apply money received
from any non-Florida Medicaid source to charges related to a claim paid by
Florida Medicaid (also known as "balance billing").
4. Turn a recipient's overdue account over to
a collection agency, except in circumstances as specified in paragraph (2)(a),
above.
(3) Cost
of Doing Business. Florida Medicaid does not reimburse for time spent
completing and submitting Florida Medicaid claims or time spent responding to
an audit.
(4) Emergency Medicaid
For Aliens. Florida Medicaid covers emergency services provided to aliens who
meet all Florida Medicaid eligibility requirements except for citizenship or
alien status, as follows:
(a) Eligibility is
only authorized for the duration of the emergency.
(b) Florida Medicaid does not cover
continuous or episodic services after the emergency has been
alleviated.
(c) Providers must
submit documentation establishing the emergency nature of the service with the
claim for reimbursement. Exceptions are labor, delivery, and dialysis services,
which are considered emergencies and are payable without documentation when the
emergency indicator is entered on the claim form.
(5) Free Choice of Providers. Recipients may
obtain services from any qualified Florida Medicaid provider that agrees to
provide the services in accordance with Title 42, Code of Federal Regulations
(CFR), section 431.51, except:
(a) Allowable
restrictions specified in section 1915(a) of the Social Security Act.
(b) When the recipient is enrolled in a
Florida Medicaid managed care program. Managed care plans may not restrict
enrollee choice for a family planning provider and must cover family planning
services regardless of whether the provider is in the managed care plan's
provider network.
(6)
Inmates of a Public Institution. Florida Medicaid does not cover services
provided to individuals residing in public institutions as defined in
42 CFR
435.1009 and Section
409.9025, F.S. These individuals
include those residing in correctional and holding facilities for prisoners who
meet either of the following:
(a) Have been
arrested or detained pending disposition of charges.
(b) Held under court order as material
witnesses or juveniles.
(7) Gender Dysphoria.
(a) Florida Medicaid does not cover the
following services for the treatment of gender dysphoria:
1. Puberty blockers;
2. Hormones and hormone
antagonists;
3. Sex reassignment
surgeries; and
4. Any other
procedures that alter primary or secondary sexual
characteristics.
(b) For
the purpose of determining medical necessity, including Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT), the services listed in
subparagraph (7)(a) do not meet the definition of medical necessity in
accordance with Rule 59G-1.010,
F.A.C.
(8) Out-of-State
Services.
(a) Emergency. Florida Medicaid
covers emergency services provided out-of-state without a referral, or
authorization, when the recipient's health will be endangered if the care and
services are postponed until returning to Florida.
(b) Non-Emergency. Florida Medicaid covers
services performed out-of-state, in accordance with the service-specific
coverage policy, when both of the following are met:
1. The recipient's primary care or specialist
physician refers the recipient for services.
2. Services are prior authorized by the
Florida Medicaid quality improvement organization in accordance with Florida
Medicaid's Authorization Requirements Policy, as incorporated by reference in
Rule 59G-1.053,
F.A.C.
(c) Florida
Medicaid does not cover services for recipients living out-of-state who are
enrolled under the Title-IV-E Florida foster or adoption
subsidy.
(9) Payment in
Full. Providers must accept payment from Florida Medicaid as payment in full,
except for Florida Medicaid copayments and coinsurance. For information on
copayment requirements and exemptions, refer to Florida Medicaid's General
Policies on copayment and coinsurance.
(10) Recipients or Providers that are Out of
the Country. Florida Medicaid does not cover services provided to recipients
when they are outside of the United States (U.S.), or for services rendered by
providers who are not in the U.S.
(11) Refusal of Services.
(a) Providers may not refuse to provide a
covered Florida Medicaid service to a recipient solely because the recipient's
eligibility does not display in the Florida Medicaid Management Information
System, if the recipient has a valid temporary proof of eligibility from the
Department of Children and Families, or proof of presumptive
eligibility.
(b) Right to Refuse
Services. Providers may limit the number of Florida Medicaid recipients the
provider serves, and accept or reject recipients in accordance with the
policies of the facility or practice, except as follows:
1. A hospital may not refuse to provide
emergency services in accordance with the 1986 Emergency Medical Treatment and
Active Labor Act.
2. Providers may
not deny services to recipients based solely upon race, creed, color, national
origin, disabling condition, or disability, in accordance with federal
anti-discrimination laws.
(12) Solicitation (Patient Brokering).
Providers may not knowingly solicit, offer, pay, or receive any payment,
including any kickback, bribe, or rebate, directly or indirectly, overtly or
covertly, in cash or in kind, in return for referring an individual to a person
for furnishing, or arranging for the furnishing of, any item or service for
which payment may be made, in whole or in part, under the Florida Medicaid
program, or in return for obtaining, purchasing, leasing, ordering, or
arranging for, or recommending, obtaining, purchasing, leasing, or ordering any
goods, facility, item, or service, for which payment may be made, in whole or
in part, under the Florida Medicaid program.
Rulemaking Authority 409.919, 409.961 FS. Law Implemented
409.902, 409.9025, 409.973 FS.
New 3-11-18, Amended
8-21-22.
