House Bill 2329
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Florida House of Representatives - 2000 HB 2329
By the Committee on Health Care Services and
Representative Peaden
1 A bill to be entitled
2 An act relating to health care; amending s.
3 409.212, F.S.; providing for periodic increase
4 in the optional state supplementation rate;
5 amending s. 409.901, F.S.; amending definitions
6 of terms used in ss. 409.910-409.920, F.S.;
7 amending s. 409.902, F.S.; providing that the
8 Department of Children and Family Services is
9 responsible for Medicaid eligibility
10 determinations; amending s. 409.903, F.S.;
11 providing responsibility for determinations of
12 eligibility for payments for medical assistance
13 and related services; amending s. 409.905,
14 F.S.; increasing the maximum amount that may be
15 paid under Medicaid for hospital outpatient
16 services; amending s. 409.906, F.S.; allowing
17 the Department of Children and Family Services
18 to transfer funds to the Agency for Health Care
19 Administration to cover state match
20 requirements as specified; amending s. 409.907,
21 F.S.; specifying grounds on which provider
22 applications may be denied; amending s.
23 409.908, F.S.; increasing the maximum amount of
24 reimbursement allowable to Medicaid providers
25 for hospital inpatient care; creating s.
26 409.9119, F.S.; creating a disproportionate
27 share program for children's hospitals;
28 providing formulas governing payments made to
29 hospitals under the program; providing for
30 withholding payments from a hospital that is
31 not complying with agency rules; amending s.
1
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1 409.912, F.S.; providing for the transfer of
2 certain unexpended Medicaid funds from the
3 Department of Elderly Affairs to the Agency for
4 Health Care Administration; amending s.
5 409.919, F.S.; providing for the adoption and
6 the transfer of certain rules relating to the
7 determination of Medicaid eligibility;
8 authorizing developmental research schools to
9 participate in the Medicaid certified school
10 match program; providing for the Agency for
11 Health Care Administration to seek a federal
12 waiver allowing the agency to undertake a pilot
13 project that involves contracting with skilled
14 nursing facilities for the provision of
15 rehabilitation services to adult ventilator
16 dependent patients; providing for evaluation of
17 the pilot program; providing for a report;
18 repealing s. 409.912(4)(b), F.S., relating to
19 the authorization of the agency to contract
20 with certain prepaid health care services
21 providers; providing an effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Subsection (6) of section 409.212, Florida
26 Statutes, is renumbered as subsection (7) and a new subsection
27 (6) is added to said section, to read:
28 409.212 Optional supplementation.--
29 (6) The optional state supplementation rate shall be
30 increased by the cost-of-living adjustment to the federal
31
2
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1 benefits rate provided the average state optional
2 supplementation contribution does not increase as a result.
3 Section 2. Subsections (3), (15), and (18) of section
4 409.901, Florida Statutes, are amended to read:
5 409.901 Definitions.--As used in ss. 409.901-409.920,
6 except as otherwise specifically provided, the term:
7 (3) "Applicant" means an individual whose written
8 application for medical assistance provided by Medicaid under
9 ss. 409.903-409.906 has been submitted to the Department of
10 Children and Family Services agency, or to the Social Security
11 Administration if the application is for Supplemental Security
12 Income, but has not received final action. This term includes
13 an individual, who need not be alive at the time of
14 application, whose application is submitted through a
15 representative or a person acting for the individual.
16 (15) "Medicaid program" means the program authorized
17 under Title XIX of the federal Social Security Act which
18 provides for payments for medical items or services, or both,
19 on behalf of any person who is determined by the Department of
20 Children and Family Services, or, for Supplemental Security
21 Income, by the Social Security Administration, to be eligible
22 on the date of service for Medicaid assistance.
23 (18) "Medicaid recipient" or "recipient" means an
24 individual whom the Department of Children and Family
25 Services, or, for Supplemental Security Income, by the Social
26 Security Administration, determines is eligible, pursuant to
27 federal and state law, to receive medical assistance and
28 related services for which the agency may make payments under
29 the Medicaid program. For the purposes of determining
30 third-party liability, the term includes an individual
31 formerly determined to be eligible for Medicaid, an individual
3
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1 who has received medical assistance under the Medicaid
2 program, or an individual on whose behalf Medicaid has become
3 obligated.
4 Section 3. Section 409.902, Florida Statutes, is
5 amended to read:
6 409.902 Designated single state agency; payment
7 requirements; program title.--The Agency for Health Care
8 Administration is designated as the single state agency
9 authorized to make payments for medical assistance and related
10 services under Title XIX of the Social Security Act. These
11 payments shall be made, subject to any limitations or
12 directions provided for in the General Appropriations Act,
13 only for services included in the program, shall be made only
14 on behalf of eligible individuals, and shall be made only to
15 qualified providers in accordance with federal requirements
16 for Title XIX of the Social Security Act and the provisions of
17 state law. This program of medical assistance is designated
18 the "Medicaid program." The Department of Children and Family
19 Services is responsible for Medicaid eligibility
20 determinations, including, but not limited to, policy, rules,
21 and the agreement with the Social Security Administration for
22 Medicaid eligibility determinations for Supplemental Security
23 Income recipients, as well as the actual determination of
24 eligibility.
25 Section 4. Section 409.903, Florida Statutes, is
26 amended to read:
27 409.903 Mandatory payments for eligible persons.--The
28 agency shall make payments for medical assistance and related
29 services on behalf of the following persons who the
30 department, or the Social Security Administration by contract
31 with the Department of Children and Family Services, agency
4
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1 determines to be eligible, subject to the income, assets, and
2 categorical eligibility tests set forth in federal and state
3 law. Payment on behalf of these Medicaid eligible persons is
4 subject to the availability of moneys and any limitations
5 established by the General Appropriations Act or chapter 216.
6 (1) Low-income families with children are eligible for
7 Medicaid provided they meet the following requirements:
8 (a) The family includes a dependent child who is
9 living with a caretaker relative.
10 (b) The family's income does not exceed the gross
11 income test limit.
12 (c) The family's countable income and resources do not
13 exceed the applicable Aid to Families with Dependent Children
14 (AFDC) income and resource standards under the AFDC state plan
15 in effect in July 1996, except as amended in the Medicaid
16 state plan to conform as closely as possible to the
17 requirements of the WAGES Program as created in s. 414.015, to
18 the extent permitted by federal law.
19 (2) A person who receives payments from, who is
20 determined eligible for, or who was eligible for but lost cash
21 benefits from the federal program known as the Supplemental
22 Security Income program (SSI). This category includes a
23 low-income person age 65 or over and a low-income person under
24 age 65 considered to be permanently and totally disabled.
25 (3) A child under age 21 living in a low-income,
26 two-parent family, and a child under age 7 living with a
27 nonrelative, if the income and assets of the family or child,
28 as applicable, do not exceed the resource limits under the
29 WAGES Program.
30 (4) A child who is eligible under Title IV-E of the
31 Social Security Act for subsidized board payments, foster
5
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1 care, or adoption subsidies, and a child for whom the state
2 has assumed temporary or permanent responsibility and who does
3 not qualify for Title IV-E assistance but is in foster care,
4 shelter or emergency shelter care, or subsidized adoption.
5 (5) A pregnant woman for the duration of her pregnancy
6 and for the post partum period as defined in federal law and
7 rule, or a child under age 1, if either is living in a family
8 that has an income which is at or below 150 percent of the
9 most current federal poverty level, or, effective January 1,
10 1992, that has an income which is at or below 185 percent of
11 the most current federal poverty level. Such a person is not
12 subject to an assets test. Further, a pregnant woman who
13 applies for eligibility for the Medicaid program through a
14 qualified Medicaid provider must be offered the opportunity,
15 subject to federal rules, to be made presumptively eligible
16 for the Medicaid program.
17 (6) A child born after September 30, 1983, living in a
18 family that has an income which is at or below 100 percent of
19 the current federal poverty level, who has attained the age of
20 6, but has not attained the age of 19. In determining the
21 eligibility of such a child, an assets test is not required.
22 (7) A child living in a family that has an income
23 which is at or below 133 percent of the current federal
24 poverty level, who has attained the age of 1, but has not
25 attained the age of 6. In determining the eligibility of such
26 a child, an assets test is not required.
27 (8) A person who is age 65 or over or is determined by
28 the agency to be disabled, whose income is at or below 100
29 percent of the most current federal poverty level and whose
30 assets do not exceed limitations established by the agency.
31 However, the agency may only pay for premiums, coinsurance,
6
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1 and deductibles, as required by federal law, unless additional
2 coverage is provided for any or all members of this group by
3 s. 409.904(1).
4 Section 5. Subsection (6) of section 409.905, Florida
5 Statutes, is amended to read:
6 409.905 Mandatory Medicaid services.--The agency may
7 make payments for the following services, which are required
8 of the state by Title XIX of the Social Security Act,
9 furnished by Medicaid providers to recipients who are
10 determined to be eligible on the dates on which the services
11 were provided. Any service under this section shall be
12 provided only when medically necessary and in accordance with
13 state and federal law. Nothing in this section shall be
14 construed to prevent or limit the agency from adjusting fees,
15 reimbursement rates, lengths of stay, number of visits, number
16 of services, or any other adjustments necessary to comply with
17 the availability of moneys and any limitations or directions
18 provided for in the General Appropriations Act or chapter 216.
19 (6) HOSPITAL OUTPATIENT SERVICES.--The agency shall
20 pay for preventive, diagnostic, therapeutic, or palliative
21 care and other services provided to a recipient in the
22 outpatient portion of a hospital licensed under part I of
23 chapter 395, and provided under the direction of a licensed
24 physician or licensed dentist, except that payment for such
25 care and services is limited to $1,500 $1,000 per state fiscal
26 year per recipient, unless an exception has been made by the
27 agency, and with the exception of a Medicaid recipient under
28 age 21, in which case the only limitation is medical
29 necessity.
30 Section 6. Subsection (5) of section 409.906, Florida
31 Statutes, is amended to read:
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1 409.906 Optional Medicaid services.--Subject to
2 specific appropriations, the agency may make payments for
3 services which are optional to the state under Title XIX of
4 the Social Security Act and are furnished by Medicaid
5 providers to recipients who are determined to be eligible on
6 the dates on which the services were provided. Any optional
7 service that is provided shall be provided only when medically
8 necessary and in accordance with state and federal law.
9 Nothing in this section shall be construed to prevent or limit
10 the agency from adjusting fees, reimbursement rates, lengths
11 of stay, number of visits, or number of services, or making
12 any other adjustments necessary to comply with the
13 availability of moneys and any limitations or directions
14 provided for in the General Appropriations Act or chapter 216.
15 If necessary to safeguard the state's systems of providing
16 services to elderly and disabled persons and subject to the
17 notice and review provisions of s. 216.177, the Governor may
18 direct the Agency for Health Care Administration to amend the
19 Medicaid state plan to delete the optional Medicaid service
20 known as "Intermediate Care Facilities for the Developmentally
21 Disabled." Optional services may include:
22 (5) CASE MANAGEMENT SERVICES.--The agency may pay for
23 primary care case management services rendered to a recipient
24 pursuant to a federally approved waiver, and targeted case
25 management services for specific groups of targeted
26 recipients, for which funding has been provided and which are
27 rendered pursuant to federal guidelines. The agency is
28 authorized to limit reimbursement for targeted case management
29 services in order to comply with any limitations or directions
30 provided for in the General Appropriations Act.
31 Notwithstanding s. 216.292, the Department of Children and
8
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1 Family Services may transfer general funds to the Agency for
2 Health Care Administration to fund state match requirements
3 exceeding the amount specified in the General Appropriations
4 Act for targeted case management services.
5 Section 7. Subsections (9) and (10) of section
6 409.907, Florida Statutes, are amended to read:
7 409.907 Medicaid provider agreements.--The agency may
8 make payments for medical assistance and related services
9 rendered to Medicaid recipients only to an individual or
10 entity who has a provider agreement in effect with the agency,
11 who is performing services or supplying goods in accordance
12 with federal, state, and local law, and who agrees that no
13 person shall, on the grounds of handicap, race, color, or
14 national origin, or for any other reason, be subjected to
15 discrimination under any program or activity for which the
16 provider receives payment from the agency.
17 (9) Upon receipt of a completed, signed, and dated
18 application, and completion of any necessary background
19 investigation and criminal history record check, the agency
20 must either:
21 (a) Enroll the applicant as a Medicaid provider; or
22 (b) Deny the application if the agency finds that,
23 based on the grounds listed in subsection (10), it is in the
24 best interest of the Medicaid program to do so, specifying the
25 reasons for denial. The agency may consider the factors listed
26 in subsection (10), as well as any other factor that could
27 affect the effective and efficient administration of the
28 program, including, but not limited to, the current
29 availability of medical care, services, or supplies to
30 recipients, taking into account geographic location and
31 reasonable travel time.
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1 (10) The agency may consider whether deny enrollment
2 in the Medicaid program to a provider if the provider, or any
3 officer, director, agent, managing employee, or affiliated
4 person, or any partner or shareholder having an ownership
5 interest equal to 5 percent or greater in the provider if the
6 provider is a corporation, partnership, or other business
7 entity, has:
8 (a) Made a false representation or omission of any
9 material fact in making the application, including the
10 submission of an application that conceals the controlling or
11 ownership interest of any officer, director, agent, managing
12 employee, affiliated person, or partner or shareholder who may
13 not be eligible to participate;
14 (b) Been or is currently excluded, suspended,
15 terminated from, or has involuntarily withdrawn from
16 participation in, Florida's Medicaid program or any other
17 state's Medicaid program, or from participation in any other
18 governmental or private health care or health insurance
19 program;
20 (c) Been convicted of a criminal offense relating to
21 the delivery of any goods or services under Medicaid or
22 Medicare or any other public or private health care or health
23 insurance program including the performance of management or
24 administrative services relating to the delivery of goods or
25 services under any such program;
26 (d) Been convicted under federal or state law of a
27 criminal offense related to the neglect or abuse of a patient
28 in connection with the delivery of any health care goods or
29 services;
30 (e) Been convicted under federal or state law of a
31 criminal offense relating to the unlawful manufacture,
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1 distribution, prescription, or dispensing of a controlled
2 substance;
3 (f) Been convicted of any criminal offense relating to
4 fraud, theft, embezzlement, breach of fiduciary
5 responsibility, or other financial misconduct;
6 (g) Been convicted under federal or state law of a
7 crime punishable by imprisonment of a year or more which
8 involves moral turpitude;
9 (h) Been convicted in connection with the interference
10 or obstruction of any investigation into any criminal offense
11 listed in this subsection;
12 (i) Been found to have violated federal or state laws,
13 rules, or regulations governing Florida's Medicaid program or
14 any other state's Medicaid program, the Medicare program, or
15 any other publicly funded federal or state health care or
16 health insurance program, and been sanctioned accordingly;
17 (j) Been previously found by a licensing, certifying,
18 or professional standards board or agency to have violated the
19 standards or conditions relating to licensure or certification
20 or the quality of services provided; or
21 (k) Failed to pay any fine or overpayment properly
22 assessed under the Medicaid program in which no appeal is
23 pending or after resolution of the proceeding by stipulation
24 or agreement, unless the agency has issued a specific letter
25 of forgiveness or has approved a repayment schedule to which
26 the provider agrees to adhere.
27 Section 8. Paragraph (a) of subsection (1) of section
28 409.908, Florida Statutes, is amended to read:
29 409.908 Reimbursement of Medicaid providers.--Subject
30 to specific appropriations, the agency shall reimburse
31 Medicaid providers, in accordance with state and federal law,
11
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1 according to methodologies set forth in the rules of the
2 agency and in policy manuals and handbooks incorporated by
3 reference therein. These methodologies may include fee
4 schedules, reimbursement methods based on cost reporting,
5 negotiated fees, competitive bidding pursuant to s. 287.057,
6 and other mechanisms the agency considers efficient and
7 effective for purchasing services or goods on behalf of
8 recipients. Payment for Medicaid compensable services made on
9 behalf of Medicaid eligible persons is subject to the
10 availability of moneys and any limitations or directions
11 provided for in the General Appropriations Act or chapter 216.
12 Further, nothing in this section shall be construed to prevent
13 or limit the agency from adjusting fees, reimbursement rates,
14 lengths of stay, number of visits, or number of services, or
15 making any other adjustments necessary to comply with the
16 availability of moneys and any limitations or directions
17 provided for in the General Appropriations Act, provided the
18 adjustment is consistent with legislative intent.
19 (1) Reimbursement to hospitals licensed under part I
20 of chapter 395 must be made prospectively or on the basis of
21 negotiation.
22 (a) Reimbursement for inpatient care is limited as
23 provided for in s. 409.905(5). Reimbursement for hospital
24 outpatient care is limited to $1,500 $1,000 per state fiscal
25 year per recipient, except for:
26 1. Such care provided to a Medicaid recipient under
27 age 21, in which case the only limitation is medical
28 necessity;
29 2. Renal dialysis services; and
30 3. Other exceptions made by the agency.
31
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1 Section 9. Section 409.9119, Florida Statutes, is
2 created to read:
3 409.9119 Disproportionate share program for children's
4 hospitals.--In addition to the payments made under s. 409.911,
5 the Agency for Health Care Administration shall develop and
6 implement a system under which disproportionate share payments
7 are made to those hospitals that are licensed by the state as
8 a children's hospital. This system of payments must conform to
9 federal requirements and must distribute funds in each fiscal
10 year for which an appropriation is made by making quarterly
11 Medicaid payments. Notwithstanding s. 409.915, counties are
12 exempt from contributing toward the cost of this special
13 reimbursement for hospitals that serve a disproportionate
14 share of low-income patients.
15 (1) The agency shall use the following formula to
16 calculate the total amount earned for hospitals that
17 participate in the children's hospital disproportionate share
18 program:
19 TAE = DSR x BMPD x MD
20 Where:
21 TAE = total amount earned by a children's hospital.
22 DSR = disproportionate share rate.
23 BMPD = base Medicaid per diem.
24 MD = Medicaid days.
25 (2) The agency shall calculate the total additional
26 payment for hospitals that participate in the children's
27 hospital disproportionate share program as follows:
28
29 TAP = (TAE x TA)
30
31 STAE
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1 Where:
2 TAP = total additional payment for a children's
3 hospital.
4 TAE = total amount earned by a children's hospital.
5 STAE = sum of total amount earned by each hospital that
6 participates in the children's hospital disproportionate share
7 program.
8 TA = total appropriation for the children's hospital
9 disproportionate share program.
10
11 (3) A hospital may not receive any payments under this
12 section until it achieves full compliance with the applicable
13 rules of the agency. A hospital that is not in compliance for
14 two or more consecutive quarters may not receive its share of
15 the funds. Any forfeited funds must be distributed to the
16 remaining participating children's hospitals that are in
17 compliance.
18 Section 10. Subsection (9) of section 409.912, Florida
19 Statutes, is amended to read:
20 409.912 Cost-effective purchasing of health care.--The
21 agency shall purchase goods and services for Medicaid
22 recipients in the most cost-effective manner consistent with
23 the delivery of quality medical care. The agency shall
24 maximize the use of prepaid per capita and prepaid aggregate
25 fixed-sum basis services when appropriate and other
26 alternative service delivery and reimbursement methodologies,
27 including competitive bidding pursuant to s. 287.057, designed
28 to facilitate the cost-effective purchase of a case-managed
29 continuum of care. The agency shall also require providers to
30 minimize the exposure of recipients to the need for acute
31
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1 inpatient, custodial, and other institutional care and the
2 inappropriate or unnecessary use of high-cost services.
3 (9) The agency, after notifying the Legislature, may
4 apply for waivers of applicable federal laws and regulations
5 as necessary to implement more appropriate systems of health
6 care for Medicaid recipients and reduce the cost of the
7 Medicaid program to the state and federal governments and
8 shall implement such programs, after legislative approval,
9 within a reasonable period of time after federal approval.
10 These programs must be designed primarily to reduce the need
11 for inpatient care, custodial care and other long-term or
12 institutional care, and other high-cost services.
13 (a) Prior to seeking legislative approval of such a
14 waiver as authorized by this subsection, the agency shall
15 provide notice and an opportunity for public comment. Notice
16 shall be provided to all persons who have made requests of the
17 agency for advance notice and shall be published in the
18 Florida Administrative Weekly not less than 28 days prior to
19 the intended action.
20 (b) Notwithstanding s. 216.292, funds that are
21 appropriated to the Department of Elderly Affairs for the
22 Assisted Living for the Elderly Medicaid waiver and are not
23 expended shall be transferred to the agency to fund
24 Medicaid-reimbursed nursing home care.
25 Section 11. Section 409.919, Florida Statutes, is
26 amended to read:
27 409.919 Rules.--The agency shall adopt any rules
28 necessary to comply with or administer ss. 409.901-409.920 and
29 all rules necessary to comply with federal requirements. In
30 addition, the Department of Children and Family Services shall
31 adopt and accept transfer of any rules necessary to carry out
15
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1 its responsibilities for receiving and processing Medicaid
2 applications and determining Medicaid eligibility, and for
3 assuring compliance with and administering ss. 409.901-409.906
4 and any other provisions related to responsibility for the
5 determination of Medicaid eligibility.
6 Section 12. Notwithstanding the provisions of ss.
7 236.0812, 409.9071, and 409.908(21), Florida Statutes,
8 developmental research schools, as authorized under s.
9 228.053, Florida Statutes, shall be authorized to participate
10 in the Medicaid certified school match program subject to the
11 provisions of ss. 236.0812, 409.9071, and 409.908(21), Florida
12 Statutes.
13 Section 13. (1) The Agency for Health Care
14 Administration is directed to submit to the Health Care
15 Financing Administration a request for a waiver that will
16 allow the agency to undertake a pilot project that would
17 implement a coordinated system of care for adult ventilator
18 dependent patients. Under this pilot program, the agency shall
19 identify a network of skilled nursing facilities that have
20 respiratory departments geared towards intensive treatment and
21 rehabilitation of adult ventilator patients and will contract
22 with such a network for respiratory services under a
23 capitation arrangement. The pilot project must allow the
24 agency to evaluate a coordinated and focused system of care
25 for adult ventilator dependent patients to determine the
26 overall cost-effectiveness and improved outcomes for
27 participants.
28 (2) The agency shall submit the waiver by September 1,
29 2000. The agency shall forward a preliminary report of the
30 pilot project's findings to the Governor, the Speaker of the
31 House of Representatives, and the President of the Senate 6
16
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1 months after project implementation. The agency shall submit
2 a final report of the pilot project's findings to the
3 Governor, the Speaker of the House of Representatives, and the
4 President of the Senate no later than February 15, 2002.
5 Section 14. Paragraph (b) of subsection (4) of section
6 409.912, Florida Statutes, is repealed.
7 Section 15. This act shall take effect July 1, 2000.
8
9 *****************************************
10 HOUSE SUMMARY
11
Revises provisions relating to provision of health care
12 under Medicaid to: make the Department of Children and
Family Services responsible for Medicaid eligibility
13 determinations; provide responsibility for determinations
of eligibility for payments for medical assistance and
14 related services; increase the maximum amount that may be
paid under Medicaid for hospital outpatient services;
15 allow the Department of Children and Family Services to
transfer funds to the Agency for Health Care
16 Administration to fund state match requirements; specify
grounds on which provider applications may be denied;
17 increase the maximum amount of reimbursement allowable to
Medicaid providers for hospital inpatient care; create a
18 disproportionate share program for children's hospitals,
provide formulas governing payments made to hospitals
19 under the program, and provide for withholding payments
from a hospital that is not complying with agency rules;
20 provide for the transfer of unexpended Medicaid funds
from the Department of Elderly Affairs to the Agency for
21 Health Care Administration; provide for the adoption and
the transfer of rules relating to the determination of
22 Medicaid eligibility; authorize developmental research
schools to participate in a Medicaid certified school
23 match program; provide for the Agency for Health Care
Administration to seek a federal waiver allowing the
24 agency to undertake a pilot project that involves
contracting with skilled nursing facilities for the
25 provision of rehabilitation services to adult ventilator
dependent patients and provide for evaluating the pilot
26 program. See bill for details.
27
28
29
30
31
17