Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59G - Medicaid
Chapter 59G-6 - REIMBURSEMENT TO PROVIDERS
Section 59G-6.025 - Reimbursement Methodology for Cancer Hospitals
Universal Citation: FL Admin Code R 59G-6.025
Current through Reg. 50, No. 187; September 24, 2024
(1) This rule applies to Florida Medicaid providers that render inpatient and outpatient hospital services to recipients through the fee-for-service delivery system. The providers must be considered as a cancer hospital and:
(a) Be members of
the Alliance of Dedicated Cancer Centers.
(b) Meet the criteria under
Title 42, United States Code, section
1395ww(d)(1)(B)(v).
(2) Definitions.
(a) Upper Payment Limit (UPL) - The annual
maximum amount Florida Medicaid may pay in the aggregate to inpatient hospitals
for inpatient and outpatient services rendered under the Florida Medicaid
fee-for-service delivery system.
(b) UPL Gap - The difference between the
annual maximum amount Medicare would pay to a cancer hospital for inpatient and
outpatient hospital services rendered to recipients and the actual amount paid
by Florida Medicaid for those services.
(c) Valid Claim - A "clean claim" as defined
in rule 59G-1.010, F.A.C., for inpatient
and outpatient hospital services that meet all of the following:
1. Provided by a cancer hospital under the
fee-for-service delivery system.
2.
Provided to Florida Medicaid recipients who are not also eligible for
Medicare.
(3) Reimbursement.
(a) Effective October 26,
2017, Florida Medicaid reimburses cancer hospitals for inpatient and outpatient
hospital services rendered to eligible Florida Medicaid recipients in an amount
up to each hospital's UPL, in accordance with Title 42, Code of Federal
Regulations (CFR), section 447.272.
(b) Florida Medicaid calculates supplemental
payments to cancer hospitals based upon the UPL gap.
(c) Florida Medicaid reimbursement to
providers for state fiscal year (SFY) 2017-2018 will be prorated by using the
ratio of effective dates within SFY 2017-2018 and multiplying the ratio by the
UPL gap for hospital inpatient and outpatient services. The calculated ratio
for SFY 2017-2018 is 0.6795.
(d)
Florida Medicaid will calculate supplemental payments quarterly, based on valid
claims that have a paid date within the previous three
months.
Rulemaking Authority 409.919 FS. Law Implemented 409.905, 409.908 FS.
New 5-13-19.
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