Current through Reg. 50, No. 187; September 24, 2024
(1) This rule applies to all hospitals and
ambulatory surgical centers (ASC) rendering Florida Medicaid outpatient
hospital services to recipients, in accordance with rules
59G-4.160 and
59G-4.020, Florida
Administrative Code, (F.A.C.), respectively.
(2) Definitions.
(a) Annual Appropriation - The funding
provided in the General Appropriations Act and the incorporated Medicaid
Hospital Funding Programs document.
(b) Automatic Rate Enhancement - An
additional fee applied to each payable claim line.
(c) Base Rate - An amount calculated using 12
months of historical claims data.
(d) Base Year - A period of historical claims
extracted for a pricing simulation.
(e) Bundled EAPG Payment - A single payment
applied to one claim line that includes reimbursement for services reported on
multiple claim lines.
(f) Charge
Cap - A limitation that ensures the Medicaid-allowed amount does not exceed the
submitted charges on either individual service line(s), or overall for the
entire outpatient claim.
(g)
Crossover Claim - Provider claim for services provided to recipients who are
eligible for Medicare and Medicaid services, or who have other third-party
insurance.
(h) Discounting Claim
Line - A service line on a claim where the payment is adjusted.
(i) Enhanced Ambulatory Patient Groups (EAPG)
- A product of 3M Health Information Systems (HIS) that categorizes outpatient
services and procedures into groups for payment based on clinical information
present on an outpatient claim.
(j)
EAPG Code - Proprietary number developed by 3M HIS to indicate a specific
grouping of services.
(k) EAPG
Methodology - Reimbursement system that provides an all-inclusive rate for all
services and items furnished during an outpatient visit, unless otherwise
specified. The methodology categorizes the amount and type of services provided
during an outpatient visit and groups together procedures, medications,
materials, and patient factors that share similar characteristics and resource
utilization. Each category is assigned an EAPG code. Each EAPG code is assigned
a relative weight (which may equal zero) that is used to calculate
payment.
(l) Florida Medicaid
Outpatient Charges - The billed charges for outpatient services covered by the
Florida Medicaid program for a hospital or an ASC.
(m) General Hospital - As defined in section
395.002(10),
Florida Statutes (F.S.).
(n) High
Medicaid Outpatient Utilization Hospital - A hospital that renders 55 percent
or more of its total annual outpatient services to Florida Medicaid
recipients.
(o) Payment Adjustment
Factor - A multiplier used to package and consolidate payment for similar
services; or, to discount services if the services are determined to be
clinically similar to other services on the claim.
(p) Policy Adjustor - Numerical multipliers
included in the EAPG claim service line payment calculation that increase or
decrease payments to categories of services, categories of providers, or
both.
(q) Provider Rate Worksheets
- A list of the EAPG base rates and automatic rate enhancements for each
hospital and ASC.
(r) Relative
Weights - National average values calculated by 3M HIS which identify the
relative amount of resources utilized to perform the services mapped to the
EAPG code.
(s) Rural Hospital - As
defined in section 395.602(2),
F.S.
(t) Service Line Payment - A
calculation used to determine individual claim line reimbursement.
(u) Service Line Procedure Code - The
assigned Common Procedure Terminology© (CPT)
Code and Health Procedural Code System (HCPCS) included on a claim
line.
(3) Reimbursement.
Effective July 1, 2017, the Agency for Health Care Administration (AHCA) will
reimburse for Florida Medicaid outpatient hospital services rendered by
hospital and ASC providers using the EAPG payment methodology in accordance
with section 409.905, F.S.
(4) Reimbursement Methodology.
(a) EAPG Payment Calculation. The calculation
is as follows:
[(Base Rate * EAPG Relative Weight * Policy Adjustor *
Payment Adjustment Factor) (up to the $1, 500 recipient annual benefit limit,
when applicable)] + Automatic Rate Enhancement.
(b) Base Rate. AHCA will establish base
rates. The base rates for dates of service beginning July 1, 2017 through March
31, 2018 are found on the Provider EAPG Rate Worksheet FY 2017-2018,
incorporated by reference and available on the AHCA website at
http://ahca.myflorida.com/medicaid/cost_reim/archive/hospital_rates_archive.shtml#rates
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-10093.
The base rates for dates of service beginning April 1, 2018 through June 30,
2018 are found on the Provider EAPG Rate Worksheet Reconciliation, incorporated
by reference and available on the AHCA website at
http://ahca.myflorida.com/medicaid/cost_reim/hospital_rates.shtml
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-10094.
The base rates for dates of service beginning July 1, 2018
are found in Provider EAPG Rate Worksheet FY 2018-2019, incorporated by
reference and available on the AHCA website at
http://ahca.myflorida.com/medicaid/cost_reim/hospital_rates.shtml
and at http://www.flrules.org/Gateway/reference.asp?No=Ref-10095.
(c) EAPG Relative Weight. AHCA will use 3M
HIS relative weights as found on the EAPG Rate Worksheet FY 2018-19,
incorporated by reference and available on the AHCA website at
http://ahca.myflorida.com/medicaid/cost_reim/hospital_rates.shtml
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-10096.
AHCA will use the service line procedure code to determine
the EAPG code and relative weight, except in claims for evaluation and
management services without another significant procedure, wherein AHCA will
use the recipient's primary diagnosis to determine the EAPG code and relative
weight.
(d) Policy Adjustor.
AHCA will only include a provider policy adjustor in the EAPG payment for rural
hospitals and high Florida Medicaid outpatient utilization hospitals.
(e) Payment Adjustment Factor. AHCA will
establish the Payment Adjustment Factor(s) as follows:
1. The Payment Adjustment Factor will be 1.0
for claim service lines that pay in full.
2. The Payment Adjustment Factor will be zero
for bundled lines.
3. The Payment
Adjustment Factor will be 0.50 on discounting claim lines, except for bilateral
procedures.
4. The Payment
Adjustment Factor will be 1.50 for bilateral procedures.
(f) Automatic Rate Enhancements. AHCA will
apply an automatic rate enhancement to payable claim lines for outpatient
hospitals for dates of service beginning July 1, 2017 as found on the Provider
EAPG Rate Worksheet FY 2017-2018, incorporated by reference and available on
the AHCA website at:
http://ahca.myflorida.com/medicaid/cost_reim/archive/hospital_rates_archive.shtml
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-10093.
AHCA will apply an automatic rate enhancement to payable claim lines for
outpatient hospitals for dates of service beginning July 1, 2018 as found on
the Provider EAPG Rate Worksheet FY 2018-19, incorporated by reference and
available on the AHCA website at:
http://ahca.myflorida.com/medicaid/cost_reim/hospital_rates.shtml
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-10095.
1. For each hospital receiving automatic rate
enhancements, AHCA will calculate a per-payable-service-line payment amount by
dividing the annual appropriation by the number of Florida Medicaid outpatient
payable service lines in the base year.
2. AHCA will apply an automatic rate
enhancement payment as follows:
a. To claim
service lines that receive a bundled EAPG payment.
b. When adjudicated after a recipient reaches
his or her annual hospital outpatient benefit limit with claim service lines
that are paid $0.00 and have a status of paid.
3. AHCA will apply an automatic rate
enhancement payment of $0.00 to claim service lines when claim service lines
are denied.
(g) Budget
Neutrality. AHCA will reconcile the EAPG parameters to comply with budget
neutrality requirements.
(h)
Terminated Procedures. AHCA will reimburse providers for procedures that are
terminated prior to the administration of anesthesia at 50% of the
rate.
(i) Charge Cap. AHCA will not
apply a charge cap to services reimbursed under the EAPG payment
methodology.
(5)
Exclusion. AHCA will not apply the EAPG reimbursement methodology to reimburse
the following:
1. Services covered under the
transplant global fee in accordance with rule
59G-4.150, F.A.C.
2. Vagus nerve stimulator device
payments.
3. Newborn hearing
screening.
(6) Cost
Settlement. AHCA will not subject hospitals and ASCs reimbursed using the EAPG
payment methodology to retrospective cost settlement.
(7) Crossover Pricing. For hospital
outpatient crossover claims, AHCA will determine the Medicaid-allowed amount
using the EAPG pricing methodology.
Rulemaking Authority 409.919 FS. Law Implemented 409.905,
409.908, 409.913 FS.
New 12-25-18.
