Current through Reg. 50, No. 187; September 24, 2024
(1) Purpose. This rule describes the
circumstances when the Agency for Health Care Administration (AHCA) may
directly reimburse eligible Florida Medicaid recipients; how AHCA reimburses
recipients; and documentation requirements for direct reimbursement.
(2) Determination Criteria. Florida Medicaid
recipients may be eligible for direct reimbursement if:
(a) Medical goods and services were paid for
by the recipient or a person legally responsible for their bills from the date
of an erroneous denial or termination of Florida Medicaid eligibility to the
date of a reversal of the unfavorable eligibility determination.
(b) The goods and services were medically
necessary as defined in Rule
59G-1.010, Florida
Administrative Code (F.A.C.); rendered by a provider that is qualified to
perform the service including meeting any applicable certification or licensure
requirements (the provider is not required to be enrolled or registered as a
Florida Medicaid provider); and covered by Florida Medicaid for the recipient's
eligibility group on the date of service.
(c) Reimbursement for the medical goods or
services is not available through any third-party payer on the date of service
for which direct reimbursement is requested.
(3) Reimbursement Process. Recipients must
submit direct reimbursement requests to AHCA within 12 months of the date of
the reversal of the unfavorable eligibility determination described in
paragraph (2)(a).
(a) The reimbursement
request must include evidence of all out-of-pocket expenses paid to the
provider, validated through receipts submitted by the recipient to: Agency for
Health Care Administration, 2727 Mahan Drive, MS #58, Tallahassee, FL
32308.
(b) The Agency for Health
Care Administration will send a Florida Medicaid Direct Reimbursement Recipient
Information Request, AHCA Form 5240-0002, June 2016, incorporated by reference
and available on the AHCA website at
http://ahca.myflorida.com/Medicaid/review/index.shtml,
or at
http://www.flrules.org/Gateway/reference.asp?No=Ref-06750,
to recipients if more information is required to determine their eligibility
for direct reimbursement. Recipients must complete and return the signed form
in accordance with the instructions provided on the form.
(c) The Agency for Health Care Administration
will send a Florida Medicaid Direct Reimbursement Provider Information Request,
AHCA Form 5240-0003, June 2016, incorporated by reference and available on the
AHCA website at
http://ahca.myflorida.com/Medicaid/review/index.shtml,
or at
http://www.flrules.org/Gateway/reference.asp?No=Ref-06750,
if more information is needed from the provider to determine recipient
eligibility for direct reimbursement. Providers must complete and return the
signed form in accordance with the instructions provided on the
form.
(4) Recipient
Notification. The Agency for Health Care Administration will send reimbursement
directly to the recipient in the amount the recipient paid to the provider. If
AHCA determines that the expenses do not qualify for reimbursement, the
recipient will be notified in writing after all information has been
reviewed.
(5) Fair Hearing. The
recipient has the right to request a Medicaid fair hearing if notified that
reimbursement in full or in part is not approved. A request for a fair hearing
must be made within 90 days from the date the notification is mailed to the
recipient. The fair hearing may be requested by calling the Medicaid Helpline
at 1(877)254-1055 or by contacting the Department of Children and Families
Office of Appeal Hearings at
appeal.hearings@myflfamilies.com.
Rulemaking Authority 409.919 FS. Law Implemented 409.902
FS.
New 9-22-93, Formerly 10P-5.110, Amended 5-9-99,
6-2-16.
