Current through Reg. 50, No. 187; September 24, 2024
(1) This rule applies to all county health
departments (CHD)s rendering Florida Medicaid clinic services to recipients in
accordance with Rule 59G-4.055, Florida
Administrative Code, (F.A.C.).
(2)
Definitions.
(a) Allowable Cost - Cost(s)
incurred for recipient-related health care services, except as outlined in
subsection (5).
(b) Buy-back - A
provision that allows a CHD to decrease the Medicaid Trend Adjustment from the
established percent to zero percent.
(c) County Health Department (CHD) Clinic
Services - Florida Medicaid primary and preventive health care services,
related diagnostic services, and dental services.
(d) Encounter - A visit occurring on a
specific day between a recipient and health care professional(s). Two
Encounters occurring on the same day will not be reimbursed separately, even if
the Encounters are for different types of services.
(e) Filing Due Date - Date that is no later
than five calendar months after the close of a CHD's cost reporting year; or,
date that is within six months of a CHD's cost reporting year, if a certified
report is filed.
(f) Legislative
Unit Cost - The weighted average per diem of the state anticipated expenditure
after all rate reductions, but prior to any Buy-back.
(g) Medicaid Trend Adjustment - A
proportional percentage rate reduction that is uniformly applied to all Florida
Medicaid providers' Rate Period, which equals all recurring and nonrecurring
budget reductions on an annualized basis and is applied to all components of
the prospective per diem.
(h) Rate
Period - July 1 of a calendar year through June 30 of the next calendar
year.
(i) Rate Setting Due Date -
April 15: all cost reports received by Florida Medicaid on or before April 15
of each Rate Period will be used to establish the reimbursement rates for the
subsequent Rate Period.
(j) Rate
Setting Unit Cost - The weighted average per diem after all rate reductions but
prior to any Buy-backs, which is based on submitted cost
reports.
(3)
Reimbursement. The Agency for Health Care Administration (AHCA) will reimburse
for Florida Medicaid services rendered by Florida Medicaid-enrolled CHDs at a
rate-per-Encounter, based upon the total Allowable Cost for each clinic in
accordance with Section
409.908, Florida Statutes
(F.S.).
(4) Reimbursement
Methodology.
The Agency for Health Care Administration establishes
reimbursement Encounter rates for each CHD that renders services in accordance
with Title 42, Code of Federal Regulations (CFR), section 440.90. The rates
become effective on July 1 of the applicable Rate Period and are calculated as
follows:
(a) Setting Individual CHD
Rates. To determine reimbursement Encounter rates, AHCA will perform the
following:
1. Review and adjust each CHD's
cost report (available to AHCA as of the Rate Setting Due Date) to reflect the
results of desk and field audits.
2. Determine each CHD's Encounter rate by
dividing total Allowable Cost by total allowable Encounters.
3. Adjust each CHD's Encounter rate with an
inflation factor based on the Consumer Price Index (CPI) at the midpoint of the
CHD's cost reporting period divided by the CPI projected for the midpoint of
each Rate Period.
(b)
Method of Establishing Historical Rate Reductions.
1. To establish historical rate reductions,
AHCA will apply a recurring methodology that incorporates the reductions
imposed in the following manner:
a. Divide the
total amount of each recurring reduction imposed by the number of Encounters
originally used in the rate calculation for each rate setting period, which
will yield a rate reduction per diem for each Rate Period.
b. Multiply the resulting rate reduction per
diem for each Rate Period by the projected number of Encounters used in
establishing the current budget estimate, which will yield the total current
reduction amount to be applied to current rates.
c. In the event that the total current
reduction amount is greater than the historical reduction amount, AHCA will
hold the rate reduction to the historical reduction amount.
2. The recurring methodology includes an
efficiency calculation wherein the reduction amount is subtracted from the CHD
prospective rate to calculate the final prospective rate, which cannot exceed
the $180 ceiling rate nor be lower than the $100 floor rate. If the floor rate
is higher than the CHD prospective rate, the CHD prospective rate (which cannot
exceed cost) will be used.
(c) Applying Historical Reductions to Rates.
The Agency for Health Care Administration will perform the following:
1. Apply the first rate reduction based on
the calculations outlined above and proportionately reduce the rates until the
required savings is achieved.
2.
Compare the unit cost for the current rate setting to the budgeted unit cost
for state fiscal year (SFY) 2010-2011, which is ($163.10). If the unit cost for
the current rate setting is less than the budgeted unit cost for SFY 2010-2011,
no further rate reduction will be required.
3. Utilize the Buy-back CHD Clinic Services
amount provided in the General Appropriations Act for the applicable Rate
Period for rate reductions that were effective on or after July 1,
2008.
4. The total Buy-back amount
must not exceed the total reductions.
(5) Exclusion. Costs related to the following
services are excluded from each CHD's reimbursement Encounter rate and will be
reported in the cost report under non-allowable service(s):
(a) Ambulance services.
(b) Home health services.
(c) Women, Infant and Children (WIC)
certifications and recertifications.
(d) Any health care services rendered away
from the clinic, at a hospital, or a nursing home, including off-site radiology
and clinical laboratory services. However, services rendered away from the
clinic may be reimbursable under a Florida Medicaid service-specific coverage
policy, if the services were provided in accordance with the applicable
coverage policy.
(e) Prescription
drugs and immunization costs.
(6) Cost Settlement. Reimbursement rates may
be adjusted under one of the following conditions:
(a) Submission of amended cost
reports.
(b) The results of a desk
or on-site audit.
Rulemaking Authority 409.919 FS. Law Implemented 409.908,
409.913 FS.
New 6-3-93, Formerly 10P-6.090, Amended 7-21-02, 3-10-94,
11-21-04, 1-11-09, 3-24-10, 2-23-11, 5-3-12, 4-3-13, 4-23-14, 5-3-15, 8-10-15,
6-15-16, 4-12-17, 3-11-18, 2-27-20.
