Current through Reg. 50, No. 187; September 24, 2024
(1) This policy applies to all persons who
are required to notify Florida Medicaid of any third-party benefits a recipient
may have and to providers rendering Florida Medicaid services to
recipients.
(2) Purpose.
Third-party liability (TPL) refers to the legal obligation of third-parties to
pay part, or all, of the expenditures for medical assistance furnished under
the Florida Medicaid program. In accordance with Title 42, Code of Federal
Regulations (CFR), section 433, Subpart D, all other available third-party
resources must meet their legal obligation to pay claims before the Florida
Medicaid program pays for a recipient's health care services.
(3) Definitions.
(a) Dually Eligible Recipient. As defined in
rule 59G-1.010, Florida
Administrative Code (F.A.C.).
(b)
Rate. As defined in rule 59G-1.010, F.A.C.
(4) Third-Party Liability Vendor. The Agency
for Health Care Administration (AHCA) contracts with a TPL vendor to identify,
manage, and recover funds and overpayments paid on behalf of recipients when a
third-party is, or was, responsible. The TPL vendor also administers Florida
Medicaid's third-party liability recovery programs for casualty, estate, trust,
and annuities on behalf of deceased Medicaid recipients.
Information regarding AHCA's TPL vendor can be found on the
AHCA Web site at http://www.ahca.myflorida.com/Admin/.
(5) Third-Party Liability Notices.
(a) Notices regarding any third-party
benefit, including trust, annuity, or estate probate actions, must be submitted
in accordance with sections
409.910,
409.9101, Florida Statutes
(F.S.), to the appropriate address located on the AHCA Web site at
http://www.ahca.myflorida.com/Admin/.
(b) Notice provided to any other AHCA office,
or delivered to any other address, is not effective to fulfill the notice
requirements.
(6)
Exhausting Third-Party Resources.
(a) Florida
Medicaid is the payer of last resort. Providers must exhaust all TPL sources of
payment, such as Medicare, TRICARE, private health insurance, AARP plans, or
automobile coverage prior to submitting or resubmitting a claim for
reimbursement to Florida Medicaid.
(b) The following programs are exceptions to
Florida Medicaid being the payer of last resort:
1. Federal funds for the Individuals with
Disabilities Education Act, Part B or C.
2. Indian Health Services, according to
42 CFR
136.61.
3. Programs funded through state and county
funds, including:
a. Acquired Immune
Deficiency Syndrome (AIDS) drug assistance programs.
b. County health departments.
c. Department of Health indigent drug
programs.
d. Substance abuse,
mental health, and developmental disabilities programs operated by the
Department of Children and Families and the Agency for Persons with
Disabilities.
e. Victim's
compensation funds.
f. Vocational
rehabilitation programs.
(7) Refusal of Services. Providers may not
refuse to furnish a covered Florida Medicaid service to a recipient solely
because of the presence of other insurance, including Medicare, in accordance
with 42 CFR
447.20(b).
(8) Reimbursement for Services Provided to
Recipients with TPL.
(a) Florida Medicaid
reimburses the difference between the Florida Medicaid rate and the third-party
payment, minus any applicable Florida Medicaid copayment or coinsurance, unless
otherwise specified in this rule.
(b) Florida Medicaid does not reimburse for
services when:
1. The amount of any
third-party payment(s) (including Medicare) is equal to, or exceeds, the
Florida Medicaid rate for the service.
2. The provider's TPL claim is denied for
failing to obtain the appropriate authorization from the third-party. Services
approved by Medicare do not require Florida Medicaid prior
authorization.
(9) Third-Party Liability Resources.
(a) Providers must inquire if a recipient has
third-party insurance coverage and if there have been any changes to existing
third-party coverage.
(b)
Third-party liability information for a recipient, when known to Florida
Medicaid, is available for providers on the Florida Medicaid fiscal agent's Web
site at http://portal.flmmis.com/flpublic, or by phone using the Florida
Medicaid Automated Voice Response System (AVRS) at 1(800)239-7560.
(c) Providers must determine if the insurance
on the Florida Medicaid file is applicable to the services being provided.
Florida Medicaid uses the following two-digit numeric codes for each associated
insurance coverage type, when verifying recipient eligibility and for claims
processing purposes:
|
CODE
|
INSURANCE COVERAGE TYPE
|
|
03
|
BASIC SURGICAL
|
|
04
|
BASIC HOSPITAL/MEDICAL/SURGICAL
|
|
05
|
PHARMACY ADMINISTRATOR (TPA)
|
|
06
|
MAJOR MEDICAL
|
|
07
|
ACCIDENT ONLY (NON AUTO)
|
|
08
|
VEHICLE ALL INCLUSIVE
|
|
09
|
MAJOR MEDICAL WITH TPA OR NO PHARMACY
|
|
10
|
CANCER
|
|
11
|
MEDICARE SPECIAL NEED PLAN
|
|
12
|
MEDICARE SUPPLEMENT
|
|
13
|
NURSING HOME SUPPLEMENT
|
|
14
|
HEALTH MAINTENANCE ORGANIZATION
|
|
15
|
DENTAL
|
|
16
|
TRICARE
|
|
17
|
HMO WITHOUT PHARMACY
|
|
18
|
CONTINUING CARE/LIFE CARE
|
|
19
|
MEDICARE ADVANTAGE PLAN
|
|
20
|
FULLY LIABLE MEDICARE ADVANTAGE PLAN
|
|
21
|
PHARMACY CARD SERVICE
|
|
22
|
HOSPITAL ROOM - BOARD/INDEMNITY
|
|
23
|
BASIC MEDICAL
|
(d)
Discounted Contracts.
1. Florida Medicaid
reimburses providers contracted with a third-party in which the provider agrees
to accept as full payment an amount less than its customary charges. Florida
Medicaid reimbursement is limited to any remaining recipient liability, such as
a copayment or deductible.
2. If
the discount contract's allowable fee is less than Florida Medicaid's maximum
allowable rate and there remains a recipient liability, providers must:
a. Compute the amount of the recipient's
responsibility (deductible, coinsurance, etc.).
b. Deduct the result of sub-subparagraph a.
from the Florida Medicaid rate.
c.
Include the result of sub-subparagraph b. as the third-party payment on the
claim.
3. Providers must
prorate the discount contract's allowable TPL payment and the recipient
responsibility for each line item, if the explanation of benefits from the TPL
is not itemized.
(e)
Discounted Contracts for Diagnostic Related Groups (DRG) or Enhanced Ambulatory
Patient Grouping (EAPG). Providers must ensure that the Florida Medicaid
reimbursement is equal to, or less than, any contracted or negotiated TPL
rate(s) for claims reimbursed through DRG or EAPG.
(f) Contributions to a Facility.
1. Providers must treat any contribution made
to a facility on behalf of a specific recipient as a third-party payment and
include it on the claim form.
2.
Providers are not required to report a contribution made to a facility when the
contribution is not for a specific recipient, but for the benefit of all
residents.
(10)
Florida Medicaid Payments for Dually Eligible Recipients.
(a) Medicare Part A Premium. Florida Medicaid
will pay the Part A premium for dually eligible recipients with full Florida
Medicaid, Qualified Medicare Beneficiaries (QMB), Supplemental Security Income
(SSI), or Medically Needy with QMB.
(b) Medicare Part B Premium. Florida Medicaid
will pay the Part B premium for dually eligible recipients with full Florida
Medicaid, QMB, SSI, Specified Low-Income Medicare Beneficiary (SLMB), or
Qualified Individual (QI1) benefits, or Medically Needy with QMB, SLMB, or QI1
benefits. Florida Medicaid does not reimburse expenditures that could have been
paid for under Medicare Part B, but were not, because an individual was not
enrolled in Part B in accordance with
42 CFR
431.625(d). This limit
applies to all recipients who are eligible for enrollment under Part B, whether
individually or through an agreement under section 1843(a) of the Social
Security Act.
(c) Florida Medicaid
does not pay for Medicare Part C premiums.
(d) Medicare Part D.
1. Florida Medicaid reimburses for drugs that
are excluded by Medicare from Medicare Part D coverage for dually eligible
recipients who are eligible to receive prescribed drug services in accordance
with the Florida Medicaid prescribed drug services coverage policy.
2. Florida Medicaid does not pay for Medicare
Part D premiums, or for any Medicare Part D copayments, coinsurance, or
deductibles.
3. Florida Medicaid
does not reimburse for drugs for dually eligible recipients who are eligible
for Medicare Part D, but who are not enrolled.
(11) Florida Medicaid Claim Reimbursement for
Dually Eligible Recipients.
(a) Florida
Medicaid reimburses Medicare Parts A, B, and C, deductible(s), coinsurance, and
copayments for dually eligible recipients in accordance with section
409.908, F.S., based on the
lesser of the amount billed or the Florida Medicaid rate.
(b) Florida Medicaid reimbursement for dually
eligible recipients is as follows:
Subtract the Medicare paid amount, plus any other third-party
payment, from the Medicaid rate.
1. If
the calculated amount in paragraph (b) is zero or a negative amount, no payment
is made.
2. If the calculated
amount in paragraph (b) is a positive amount (rate calculation), compare the
rate calculation to the sum of the coinsurance or copayment and deductible
amounts; and, pay the lesser of these two amounts, except as otherwise
specified in section 409.908,
F.S.
(c) For Medicare
Part B services not covered by Florida Medicaid provided to dually eligible
recipients with QMB benefits (with or without other Florida Medicaid benefits)
or SSI recipients, the Florida Medicaid rate referenced in paragraph (11)(a),
above, shall be 50% of the Medicare-allowed amount and paid in accordance with
paragraphs (a) and (b) of this section.
(12) Inpatient Hospital Services for Dually
Eligible Recipients.
(a) Dually eligible
recipients with Medicare Part A or C benefits, age 21 years and older,
simultaneously deplete both Medicare and Florida Medicaid covered hospital
days.
(b) Once a dually eligible
recipient has exhausted all Medicare Part A benefits, or if the recipient does
not have Medicare Part A Coverage, the provider must:
1. Bill Medicare for Medicare-allowable Part
B inpatient ancillary services.
2.
Enter any available Medicare Part B reimbursement as TPL on the Florida
Medicaid claim for inpatient services.
(13) Florida Medicaid Patient Responsibility
for Dually Eligible Recipients. Florida Medicaid reimburses for services in
accordance with section (11) above, minus any applicable service specific
patient responsibility. Notwithstanding the requirements specified in rule
59G-4.200, F.A.C., if a
recipient has QMB benefits and is also eligible for full Florida Medicaid
benefits, or is receiving SSI, providers may not charge the patient
responsibility during the Medicare coinsurance days (day 21 up to day 100) for
nursing facility services.
(14)
Payment for Part B Nursing Facility Services for Dually Eligible Recipients.
Florida Medicaid reimburses, in accordance with the methodology specified in
paragraph (11)(a), above, for Medicare approved Part B services that are not
included in the nursing facility's cost report prepared pursuant to rule
59G-6.010, F.A.C.
(15) Timely Filing of Claims for
Reimbursement Secondary to Medicare. Providers may submit claims to Florida
Medicaid within 12 months from the date of service, or within 6 months after
AHCA or the provider receives notice of the disposition of the Medicare claim,
whichever is greater.
(16)
Fee-For-Service Exceptional Claims Process.
(a) Providers may submit claims for a Florida
Medicaid covered service when all of the following are met:
1. When the claim was denied by the Florida
Medicaid fiscal agent.
2. Any
third-party payer, or Medicare denied the claim (unless Medicare determined the
service is not medically necessary).
(b) Providers must submit fee-for-service
exceptional claims to the appropriate address listed on the AHCA Web site at
http://ahca.myflorida.com/Medicaid/Operations/assistance/providers.shtml.
Rulemaking Authority 409.910, 409.919 FS. Law Implemented
409.910, 409.9101 FS.
New 8-14-18.
