Fla. Admin. Code R. 59H-1.0045

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59H-1.0045 - County Financial Responsibility

(1) The maximum amount of HCRA funds that a county can allocate for in-county reimbursement is up to 1/2 of its total HCRA funds. No county shall have the authority to use out-of-county designated funds to supplement its in-county reimbursement amount above the aforementioned one half. Should a county exceed its designated in-county reimbursement limit, the additional funds must be provided through other funding sources from the county's budget and the amount exceeded shall not reduce the out-of-county obligation.

(2) A county's financial responsibility for each of its qualified indigent patients or spend-down provision eligible patients who received treatment in a participating hospital shall not exceed 45 days of inpatient services per county fiscal year, per applicant. If a qualified indigent patient has at least one day of coverage remaining within his/her 45-day benefit limit at the time of admission, then the eligible days shall be equal to the full length of stay.

(3) Reimbursement for treatment in a hospital emergency room for emergency medical conditions shall be at the Medicaid outpatient reimbursement rate and shall be limited to the annual Medicaid reimbursement limits as defined in Rule 59G-4.160, F.A.C.

(4) No county shall be required to pay more than the equivalent of $4 per capita as the maximum county financial responsibility in that county's fiscal year. As detailed in Section 154.306(1), F.S., the Agency shall calculate and certify to each county and hospital by March 1 of each year the maximum county financial responsibility the county shall be required to pay during the subsequent county fiscal year.

(5) For counties that are spend-down provision eligible, the rate of reimbursement to participating hospitals shall not be less than 100 percent of the reimbursement rate in effect for the hospital under the Medicaid Program, unless the county and the hospital sign a formal agreement to treat such county's indigent patients at a lower or higher negotiated rate. The county shall provide written notification to the Agency of the rate negotiated for each hospital and the effective date within 30 calendar days of the date the agreement is signed. If the due date falls on a weekend or holiday, the deadline is the next business day.

(6) For counties that are not spend-down provision eligible, the rate of reimbursement to participating hospitals shall not be less than 80 percent of the reimbursement rate in effect for the hospital under the Medicaid Program unless the county and the hospital sign a formal agreement to treat such county's indigent patients at a lower or higher negotiated rate. The county shall provide written notification to the Agency of the rate negotiated for each hospital and the effective date within 30 calendar days of the date the agreement is signed. If the due date falls on a weekend or holiday, the deadline is the next business day.

(7) The Agency will provide annually a list of Medicaid hospital outpatient and inpatient reimbursement rates which would be effective July 1, or the beginning of the state fiscal year. If a hospital does not have a Medicaid reimbursement rate provided, the Agency shall take an average of other hospitals within the same county to determine the reimbursement rate. Hospitals are responsible for notifying the county of any interim adjustments to its reimbursement rate under the Medicaid Program. The reimbursement rate utilized at the time of claim adjudication is considered the final rate for that claim. No retroactive rate adjustment is allowed.

(8) Each county shall certify to the agency, within 60 days of the end of the county's fiscal year, the amount of reimbursement it paid to all out-of-county hospitals. Additionally, should a county reach its maximum county financial responsibility before the end of the fiscal year, the county has 60 days from the date the responsibility has been met to provide the certification to the agency that the responsibility has been met. If the due date falls on a weekend or holiday, the deadline is the next business day.

(9) If there is adequate third party insurance or coverage, the county shall make payment only if such third party insurance or coverage is less than 80 percent of the reimbursement amount allowed through HCRA. Joint payment may be made on a claim by both HCRA and such third party insurance or coverage provided the combined total payment does not exceed 100 percent of the reimbursement amount allowed through HCRA.

(10) At the end of each month, each county must complete a Monthly Caseload and Appeals Report, AHCA Form 3160-0017, documenting caseload activity for the specified month and submit this report to the Agency by the 15th of the month following the end of the reported month, to the address provided on the form. If a county has no caseload activity for any month, the county must file the Caseload and Appeals Report indicating no activity. Timely filing of the report is required. Copies of the form may be located as provided in subsection 59H-1.0035(26), F.A.C.

(11) At the end of each quarter, each county must complete a Quarterly Financial Report, AHCA Form 3160-0018, for expenditures and claim activity during a specified quarter and submit this report to the Agency within 30 calendar days following the end of the reported quarter to the address provided on the report form. If the due date falls on a weekend or holiday, the deadline is the next business day. Quarters are based on the county's fiscal year. If a county has no expenditures or activity for any quarter, the county must file the Quarterly Financial Report indicating no activity. Timely filing is required to insure accurate financial information is available to determine if and when the maximum financial responsibility has been met. Copies of the form may be located as provided in subsection 59H-1.0035(33), F.A.C.

(12) When the maximum county financial responsibility has been met, the county shall notify the Agency, those hospitals with which they have agreements and those hospitals which serve county residents that the maximum county financial responsibility has been met.

(13) In order to be reimbursed, a participating hospital must have met its charity care obligation based on the most recent audited actual experience as reported and certified by the Agency's Financial Analysis Unit. As defined in Section 154.306, F.S., and subsection 59H-1.0055(5), F.A.C., the Agency will provide, to the hospitals and the counties, annually and more frequently when revised, a list of hospitals meeting their charity care obligation.

(14) Payment made to a hospital by the county under this chapter for covered services provided to an eligible individual shall be considered as payment in full and the eligible individual shall not be billed, except for the applicant's share of cost and the cost of any non-covered services.

Fla. Admin. Code Ann. R. 59H-1.0045

Rulemaking Authority 154.3105 FS. Law Implemented 154.306 FS.

New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0045, Amended 6-7-00, Amended by Florida Register Volume 42, Number 154, August 9, 2016 effective 8/25/2016.

New 3-29-89, Amended 12-24-90, 2-24-92, Formerly 10C-26.0045, Amended 6-7-00, 8-25-16.